If Your Doctor Insists That Vaccines Are Safe, Then Have Them Sign This Form

Physician's Warranty of Vaccine Safety I (Physician's name, degree)_________________________, _____ am a physician licensed to practice medicine in the State/Province of ________________, in the country of _________________. My State/Province license number is _______________ , and (if the USA) 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 justif y the recommended vaccinations. The following is a list of said risk factors and the vacci nations 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 fill ers: * aluminum hydroxide * aluminum phosphate * ammonium sulfate * amphotericin B * animal tissues: pig blood, horse blood, rabbit brain, * dog kidney, monkey kidney, * chick embryo, chicken egg, duck egg * calf (bovine) serum * 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, and * washed sheep red blood and, hereby, warrant that these ingredients are safe for injection into the body of m y 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 Simia n Virus 40 (SV 40) and that SV 40 is causally linked by some researchers to non-Hodgkin's lymphom a and mesotheliomas in humans as well as in experimental animals. I hereby wa rrant 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 t o 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 Advers e Event Reporting System) and state that it is my professional opinion that the vaccines I am rec ommending 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, -- "Physic ian's Bases for Professional Opinion of Vaccine Safety." (Please itemize each recom mended vaccine separately along with the bases for arriving at the conclusion that the vaccine is safe f or administration to a child under the age of 5 years.) The professional journal articles I have relied upon in the issuance of this Phy sician's Warranty of Vaccine Safety are itemized on Exhibit B , attached hereto, -- "Scient ific 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"
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