Tell us your story: (Please include details about the product or program you tried, the promises made, your experience with it, and any negative outcomes or effects.)
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Short Bio: (Tell us a bit about yourself, your background, and why you're passionate about sharing your story for "The Poisoning of America.")
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Video Link: Please post a link to your video from any file sharing service like Dropbox, Drive, YouTube, Vimeo, etc.
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Consent: By submitting this form, I authorize the use of my story and video for the documentary "The Poisoning of America" and understand that it may be used in promotional materials for the documentary.
A copy of your responses will be emailed to the address you provided.