Informed Consent / Vaccine Risks Disclosure Form
Here is a form you can copy and take to your doctor and/ or pediatrician, and have them fill it out and sign it. Doctors and/or pediatricians make the claim that vaccines are necessary, and as well that they are safe, and effective. They state that claim is proven; so make them actually stand behind their claim. Due to the existing and established federal vaccine court, they all know they will never have any risk of legal liability for any harm done by vaccines, and nor will any vaccine maker have any liability. Let’s go ahead and even up the level of responsibility and/or the risk here, a bit? Sound reasonable; of course it is. However, in reality quite obviously there will likely be not a one of them that will agree to fill out that form, nor to sign it. What should that tell us and the general public?
When you put this before the pro-vaccine crowd in general, watch them scramble for lame excuses as to why doctors and pediatricians should not need ever answer to these questions. The only excuse I have seen them come up with is to claim that all pharma drugs and vaccines can have some risks. So, being the CDC has blindly estimated the risk of a serious and harmful vaccine reaction is so low it is 1 in 1 million, entirely disregarding the parents statements, VAERS, with a known only 1 to 105 reporting factor, and as well disregarded the federal vaccine court payouts; THIS should put the ball in their pro-vaccine court; should it not? So, I the risk is only 1 in a million, what are they actually worried about in regard to filling out this said form? What is it that they are worried about when it comes to actually and personally backing up the safe and effective claims they make, (and don't forget all based on their epidemiological studies proclaimed science on only one vaccine and one vaccine ingredients. If they are so positive that the vaccine truth people are tin foil hat wearing and that they are only mislead conspiracy theorists; then STAND behind those vaccines are safe and effective claims! They can't do it, and they will REFUSE to do it. Take this form to your next well child visit, and prove me wrong.
If Your Doctor Cannot Answer These 4 Questions, Don't Vaccinate!
http://preventdisease.com/news/12/040212_If-Your-Doctor-Cannot-Answer-These-4-Questions-Dont-Vaccinate.shtml
Article: If Your Doctor Insists That Vaccines Are Safe, (then have them sign this form)
http://preventdisease.com/news/12/050212_If-Your-Doctor-Insists-That-Vaccines-Are-Safe-Have-Them-Sign-This-Form.shtml
PHYSICIAN'S WARRANTY OF VACCINE SAFETY
http://preventdisease.com/pdf/Warranty-of-Vaccine-Safety-English.pdf
You can use one of these two forms below, which is the same form, but with the opening title and salutation of your choosing).
Dear Responsible Doctor, (PDF document)
http://www.google.com/url?sa=t&rct=j&q=%20vaccination%2C%20dear%20responsible%20doctor&source=web&cd=2&cad=rja&ved=0CDYQFjAB&url=http%3A%2F%2Fwww.rubysemporium.org%2Fvac_consent.rtf&ei=GhPSUOm3KNH1qQGq-YGoDg&usg=AFQjCNFy-Y3uczEK5HaBWON91qHKdGKLAg
PHYSICIAN'S WARRANTY OF VACCINE SAFETY
I (Physician’s name, degree)_______________, _____ am a physician licensed to practice medicine in the State/Province of _________. My State/Provincial 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 __________________________
I am aware that vaccines may contain many of the following chemicals, excipients, preservatives and fillers:
* aluminum hydroxide
* aluminum phosphate
* ammonium sulfate
* amphotericin B
* animal tissues: pig blood, horse blood, rabbit brain,
* arginine hydrochloride
* dog kidney, monkey kidney,
* dibasic potassium phosphate
* chick embryo, chicken egg, duck egg
* calf (bovine) serum
* betapropiolactone
* fetal bovine serum
* formaldehyde
* formalin
* gelatin
* gentamicin sulfate
* glycerol
* human diploid cells (originating from human aborted fetal tissue)
* hydrocortisone
* hydrolized gelatin
* mercury thimerosol (thimerosal, Merthiolate(r))
* monosodium glutamate (MSG)
* monobasic potassium phosphate
* neomycin
* neomycin sulfate
* nonylphenol ethoxylate
* octylphenol ethoxylate
* octoxynol 10
* phenol red indicator
* phenoxyethanol (antifreeze)
* potassium chloride
* potassium diphosphate
* potassium monophosphate
* polymyxin B
* polysorbate 20
* polysorbate 80
* porcine (pig) pancreatic hydrolysate of casein
* residual MRC5 proteins
* sodium deoxycholate
* sorbitol
* thimerosal
* 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 my patient. I have researched reports to the contrary, such as reports that mercury thimerosal 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: ______________________
=================================================
-------------------------------------------------
Here as said, is another alternate, but the same form; with an alternate title and beginning salutation; your choice.
Dear Responsible Doctor, (PDF document)
http://www.google.com/url?sa=t&rct=j&q=%20vaccination%2C%20dear%20responsible%20doctor&source=web&cd=2&cad=rja&ved=0CDYQFjAB&url=http%3A%2F%2Fwww.rubysemporium.org%2Fvac_consent.rtf&ei=GhPSUOm3KNH1qQGq-YGoDg&usg=AFQjCNFy-Y3uczEK5HaBWON91qHKdGKLAg
Consent for Administration of Vaccination
Dear Responsible Doctor:
If you will be administering a vaccination to me or my child today, I will need you to complete the following consent form. Thank you.
I (physician's name) _______________________ do hereby state that I have advised my patient
(patient or child name) ____________________ and/or parent of my patient
(parent's name) _____________________ that in my professional opinion this patient/child should be given the vaccination, drug or other
(name of vaccination/drug/other) ________________________________________,
manufacturer's name _______________________,
serial number _______________,
batch number ______________________,
expiry date___________________.
I have on this (day) _________ (month) __________ (year) _________ administered this vaccination/medication/drug AFTER advising the above named patient/parent of minor patient that there is little or no risk involved with this vaccination, medication, drug therapy or treatment. I hereby do agree that should this patient/child at any time suffer or develop any permanent condition deleterious or injurious to his/her health as a result of this treatment, I will pay for any and all costs involved related to the care and treatment necessary for this patient/child for the rest of his/her natural life. I further agree that if my earnings are insufficient to meet these costs, I will sell my home, my business and all material possessions and put those proceeds towards meeting the patient-involved expenses.
Date: __________________ Signature of responsible physician: _________________________________
Signature of person administering vaccination/medication/drug: _________________________________
Occupational title: _________________ Witness (parent or other) _______________________________
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:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I am aware that vaccines typically contain many of the following fillers:
. 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
. 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
. sucrose
. 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 my patient. Reports to the contrary, such as reports that mercury thimerosol causes severe neurological and immunological damage, 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 give my assurance that the vaccines I employ in my practice do not contain SV 40 or any other live viruses. (Alternately, I hereby give my assurance that said SV-40 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 cells 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% 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% of patients who contract Hepatitis B develop no symptoms after exposure. I understand that 30% will develop only flu-like symptoms and will have lifetime immunity.
I understand that 20% will develop the symptoms of the disease, but that 95% will fully recover and have lifetime immunity. I understand that 5% of the patients who are exposed to Hepatitis B will become chronic carriers of the disease. I understand that 75% of the chronic carriers will live with an asymptomatic infection and that only 25% of the chronic carriers will develop chronic liver disease or liver cancer, 10-30 years after the acute infection. The following 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: ______________________________ Seal:
Date: ________________________
When you put this before the pro-vaccine crowd in general, watch them scramble for lame excuses as to why doctors and pediatricians should not need ever answer to these questions. The only excuse I have seen them come up with is to claim that all pharma drugs and vaccines can have some risks. So, being the CDC has blindly estimated the risk of a serious and harmful vaccine reaction is so low it is 1 in 1 million, entirely disregarding the parents statements, VAERS, with a known only 1 to 105 reporting factor, and as well disregarded the federal vaccine court payouts; THIS should put the ball in their pro-vaccine court; should it not? So, I the risk is only 1 in a million, what are they actually worried about in regard to filling out this said form? What is it that they are worried about when it comes to actually and personally backing up the safe and effective claims they make, (and don't forget all based on their epidemiological studies proclaimed science on only one vaccine and one vaccine ingredients. If they are so positive that the vaccine truth people are tin foil hat wearing and that they are only mislead conspiracy theorists; then STAND behind those vaccines are safe and effective claims! They can't do it, and they will REFUSE to do it. Take this form to your next well child visit, and prove me wrong.
If Your Doctor Cannot Answer These 4 Questions, Don't Vaccinate!
http://preventdisease.com/news/12/040212_If-Your-Doctor-Cannot-Answer-These-4-Questions-Dont-Vaccinate.shtml
Article: If Your Doctor Insists That Vaccines Are Safe, (then have them sign this form)
http://preventdisease.com/news/12/050212_If-Your-Doctor-Insists-That-Vaccines-Are-Safe-Have-Them-Sign-This-Form.shtml
PHYSICIAN'S WARRANTY OF VACCINE SAFETY
http://preventdisease.com/pdf/Warranty-of-Vaccine-Safety-English.pdf
You can use one of these two forms below, which is the same form, but with the opening title and salutation of your choosing).
Dear Responsible Doctor, (PDF document)
http://www.google.com/url?sa=t&rct=j&q=%20vaccination%2C%20dear%20responsible%20doctor&source=web&cd=2&cad=rja&ved=0CDYQFjAB&url=http%3A%2F%2Fwww.rubysemporium.org%2Fvac_consent.rtf&ei=GhPSUOm3KNH1qQGq-YGoDg&usg=AFQjCNFy-Y3uczEK5HaBWON91qHKdGKLAg
PHYSICIAN'S WARRANTY OF VACCINE SAFETY
I (Physician’s name, degree)_______________, _____ am a physician licensed to practice medicine in the State/Province of _________. My State/Provincial 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 __________________________
I am aware that vaccines may contain many of the following chemicals, excipients, preservatives and fillers:
* aluminum hydroxide
* aluminum phosphate
* ammonium sulfate
* amphotericin B
* animal tissues: pig blood, horse blood, rabbit brain,
* arginine hydrochloride
* dog kidney, monkey kidney,
* dibasic potassium phosphate
* chick embryo, chicken egg, duck egg
* calf (bovine) serum
* betapropiolactone
* fetal bovine serum
* formaldehyde
* formalin
* gelatin
* gentamicin sulfate
* glycerol
* human diploid cells (originating from human aborted fetal tissue)
* hydrocortisone
* hydrolized gelatin
* mercury thimerosol (thimerosal, Merthiolate(r))
* monosodium glutamate (MSG)
* monobasic potassium phosphate
* neomycin
* neomycin sulfate
* nonylphenol ethoxylate
* octylphenol ethoxylate
* octoxynol 10
* phenol red indicator
* phenoxyethanol (antifreeze)
* potassium chloride
* potassium diphosphate
* potassium monophosphate
* polymyxin B
* polysorbate 20
* polysorbate 80
* porcine (pig) pancreatic hydrolysate of casein
* residual MRC5 proteins
* sodium deoxycholate
* sorbitol
* thimerosal
* 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 my patient. I have researched reports to the contrary, such as reports that mercury thimerosal 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: ______________________
=================================================
-------------------------------------------------
Here as said, is another alternate, but the same form; with an alternate title and beginning salutation; your choice.
Dear Responsible Doctor, (PDF document)
http://www.google.com/url?sa=t&rct=j&q=%20vaccination%2C%20dear%20responsible%20doctor&source=web&cd=2&cad=rja&ved=0CDYQFjAB&url=http%3A%2F%2Fwww.rubysemporium.org%2Fvac_consent.rtf&ei=GhPSUOm3KNH1qQGq-YGoDg&usg=AFQjCNFy-Y3uczEK5HaBWON91qHKdGKLAg
Consent for Administration of Vaccination
Dear Responsible Doctor:
If you will be administering a vaccination to me or my child today, I will need you to complete the following consent form. Thank you.
I (physician's name) _______________________ do hereby state that I have advised my patient
(patient or child name) ____________________ and/or parent of my patient
(parent's name) _____________________ that in my professional opinion this patient/child should be given the vaccination, drug or other
(name of vaccination/drug/other) ________________________________________,
manufacturer's name _______________________,
serial number _______________,
batch number ______________________,
expiry date___________________.
I have on this (day) _________ (month) __________ (year) _________ administered this vaccination/medication/drug AFTER advising the above named patient/parent of minor patient that there is little or no risk involved with this vaccination, medication, drug therapy or treatment. I hereby do agree that should this patient/child at any time suffer or develop any permanent condition deleterious or injurious to his/her health as a result of this treatment, I will pay for any and all costs involved related to the care and treatment necessary for this patient/child for the rest of his/her natural life. I further agree that if my earnings are insufficient to meet these costs, I will sell my home, my business and all material possessions and put those proceeds towards meeting the patient-involved expenses.
Date: __________________ Signature of responsible physician: _________________________________
Signature of person administering vaccination/medication/drug: _________________________________
Occupational title: _________________ Witness (parent or other) _______________________________
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:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I am aware that vaccines typically contain many of the following fillers:
. 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
. 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
. sucrose
. 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 my patient. Reports to the contrary, such as reports that mercury thimerosol causes severe neurological and immunological damage, 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 give my assurance that the vaccines I employ in my practice do not contain SV 40 or any other live viruses. (Alternately, I hereby give my assurance that said SV-40 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 cells 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% 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% of patients who contract Hepatitis B develop no symptoms after exposure. I understand that 30% will develop only flu-like symptoms and will have lifetime immunity.
I understand that 20% will develop the symptoms of the disease, but that 95% will fully recover and have lifetime immunity. I understand that 5% of the patients who are exposed to Hepatitis B will become chronic carriers of the disease. I understand that 75% of the chronic carriers will live with an asymptomatic infection and that only 25% of the chronic carriers will develop chronic liver disease or liver cancer, 10-30 years after the acute infection. The following studies have been performed to demonstrate the safety of the Hepatitis B vaccine in children under the age of 5 years:
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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: ______________________________ Seal:
Date: ________________________
