Print out this form and have your DR. sign it before gives the shot!
http://www.reversingvaccineinduceddi...ine-Safety.pdf
Physician’s Warranty of Vaccine Safety
I (Physician’s name, degree)_________________________, _____________ am a physician
licensed to practice medicine in the State of ________________. My State license number is
______________, and my DEA number is _______________. My medical specialty is
________________________. I have a thorough understanding of the risks and benefits of all
the medications that I prescribe for or administer to my patients. In the case of (Patient’s name)
___________________________, age _________, whom I have examined, I find that certain
risk factors exist that justify the recommended vaccinations. The following is a list of said risk
factors and the vaccinations that will protect against them:
Risk Factor __________________________________________________ ________
Vaccination __________________________________________________ ________
Risk Factor __________________________________________________ ________
Vaccination __________________________________________________ ________
Risk Factor __________________________________________________ ________
Vaccination __________________________________________________ ________
Risk Factor __________________________________________________ ________
Vaccination __________________________________________________ ________
Risk Factor __________________________________________________ ________
Vaccination __________________________________________________ ________
Risk Factor __________________________________________________ ________
Vaccination __________________________________________________ ________
I am aware that vaccines typically contain many of the following fillers:
aluminum hydroxide aluminum phosphate
ammonium sulfate amphotericin B
calf (bovine) serum animal tissues: pig blood, horse blood, rabbit
brain, dog kidney, monkey kidney, chick
embryo, chicken egg, duck egg
betapropiolactone fetal bovine serum
formaldehyde formalin
gelatin glycerol
human diploid cells (originating from
human aborted fetal tissue) hydrolized gelatin
mercury thimerosol (thimerosal,
Merthiolate(r)) monosodium glutamate (MSG)
neomycin neomycin sulfate
phenol red indicator phenoxyethanol (antifreeze)
potassium diphosphate potassium monophosphate
polymyxin B polysorbate 20
polysorbate 80 porcine (pig) pancreatic hydrolysate of casein
residual MRC5 proteins sorbitol
tri(n)butylphosphate VERO cells, a continuous line of monkey
kidney cells
washed sheep red blood
and, hereby, warrant that these ingredients are safe for injection into the body of my patient. I
have researched reports to the contrary, such as reports that mercury thimerosol causes severe
neurological and immunological damage, and find that they are not credible.
I am aware that some vaccines have been found to have been contaminated with Simian
Virus 40 (SV 40) and that SV 40 is causally linked by some researchers to non-Hodgkin’s
lymphoma and mesotheliomas in humans as well as in experimental animals.
I hereby warrant that the vaccines I employ in my practice do not contain SV 40 or any other
live viruses. (Alternately, I hereby warrant that said SV-40 virus or other viruses pose no
substantive risk to my patient.)
I hereby warrant that the vaccines I am recommending for the care of (Patient’s name)
___________________________________ do not contain any tissue from aborted human babies
(also known as “fetuses”).
In order to protect my patient’s well being, I have taken the following steps to guarantee that
the vaccines I will use will contain no damaging contaminants.
STEPS TAKEN: __________________________________________________ ____________
__________________________________________________ __________________________
__________________________________________________ __________________________
__________________________________________________ __________________________
I have personally investigated the reports made to the VAERS (Vaccine Adverse Event
Reporting System) and state that it is my professional opinion that the vaccines I am
recommending are safe for administration to a child under the age of 5 years.
The bases for my opinion are itemized on Exhibit A, attached hereto, — “Physician’s Bases
for Professional Opinion of Vaccine Safety.” (Please itemize each recommended vaccine
separately along with the bases for arriving at the conclusion that the vaccine is safe for
administration to a child under the age of 5 years.)
The professional journal articles I have relied upon in the issuance of this Physician’s
Warranty of Vaccine Safety are itemized on Exhibit B , attached hereto, — “Scientific Articles
in Support of Physician’s Warranty of Vaccine Safety.”
The professional journal articles that I have read which contain opinions adverse to my
opinion are itemized on Exhibit C , attached hereto, — “Scientific Articles Contrary to
Physician’s Opinion of Vaccine Safety.”
The reasons for my determining that the articles in Exhibit C were invalid are delineated in
Attachment D , attached hereto, — “Physician’s Reasons for Determining the Invalidity of
Adverse Scientific Opinions.”
Hepatitis B
I understand that 60 percent of patients who are vaccinated for Hepatitis B will lose
detectable antibodies to Hepatitis B within 12 years. I understand that in 1996 only 54 cases of
Hepatitis B were reported to the CDC in the 0-1 year age group. I understand that in the VAERS,
there were 1,080 total reports of adverse reactions from Hepatitis B vaccine in 1996 in the 0-1
year age group, with 47 deaths reported.
I understand that 50 percent of patients who contract Hepatitis B develop no symptoms after
exposure. I understand that 30 percent will develop only flu-like symptoms and will have
lifetime immunity. I understand that 20 percent will develop the symptoms of the disease, but
that 95 percent will fully recover and have lifetime immunity.
I understand that 5 percent of the patients who are exposed to Hepatitis B will become
chronic carriers of the disease. I understand that 75 percent of the chronic carriers will live with
an asymptomatic infection and that only 25 percent of the chronic carriers will develop chronic
liver disease or liver cancer, 10-30 years after the acute infection. The following scientific
studies have been performed to demonstrate the safety of the Hepatitis B vaccine in children
under the age of 5 years.
__________________________________________________ _____________________
__________________________________________________ _____________________
__________________________________________________ _____________________
In addition to the recommended vaccinations as protections against the above cited risk
factors, I have recommended other non-vaccine measures to protect the health of my patient and
have enumerated said non-vaccine measures on Exhibit D, attached hereto, “Non-vaccine
Measures to Protect Against Risk Factors” I am issuing this Physician’s Warranty of Vaccine
Safety in my professional capacity as the attending physician to (Patient’s name)
__________________________________________. Regardless of the legal entity under which
I normally practice medicine, I am issuing this statement in both my business and individual
capacities and hereby waive any statutory, Common Law, Constitutional, UCC, international
treaty, and any other legal immunities from liability lawsuits in the instant case. I issue this
document of my own free will after consultation with competent legal counsel whose name is
__________________________________________________ ___, an attorney admitted to the
Bar in the State of __________________________________________________ ______.
______________________________________________ (Name of Attending Physician)
_________________________________________ L.S. (Signature of Attending Physician)
Signed on this _______ day of ______________ A.D. _____________________
Witness: ________________________________ Date: _____________________
Notary Public: ___________________________ Date: ______________________
