Ocean Illness Form

If you have been sick lately and think that it may be caused by ocean water contact, please tell us about it. If you have questions you want us to answer, send us a separate email.

*Required Field

Date: ,
Time of Day:
Beach is in or Closest To:
County:
Town:
Street or Break Name:
*Your Name:
Age:
*Email:
Phone Number:
Describe your illness and Symptoms:
Additional Description:
How long after you were in the ocean did your illness symptoms start?
How long did your illness last?
Did you see a doctor?
Physicians Name:
If treated, what was the diagnosis and treatment?
How many times have you been sick from the ocean at the beach you listed above?
Add any other comments you may have:
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