If Your Doctor (or Veterinarian) Insists That Vaccines Are Safe, Then Have Them Sign This Form

Written by Jan on May 29, 2012 – 8:21 pm

This vaccination consent form was designed for humans. The author suggests asking your doctor to complete and sign it before vaccinating. With a little reworking, this would work for pets — not that I believe for a moment that anyone will ever sign it. This is just about being realistic about vaccines. They are not without risk. All parties should weigh risks vs benefits in every medical procedure.

Read the original article at http://preventdisease.com/news/12/050212_If-Your-Doctor-Insists-That-Vaccines-Are-Safe-Have-Them-Sign-This-Form.shtml.  Get a printable pdf file at http://preventdisease.com/pdf/Warranty-of-Vaccine-Safety-English.pdf.   Our thanks to http://preventdisease.com for permission to reprint this.

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 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

* 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 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





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/Province of __________________.

__________________________________ (Name of Attending Physician)

__________________________________ L.S. (Signature of Attending Physician)

Signed on this _______ day of ______________ A.D. ________

Witness: _______________________________ Date: _____________________

Notary Public: ___________________________Date: ______________________


Disclaimer: This is presented for information purposes and is not a substitute for medical care.

Tags: children, consent form, informed consent, pets, Vaccination, vaccine ingredients, vaccine safety
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2 Comments to “If Your Doctor (or Veterinarian) Insists That Vaccines Are Safe, Then Have Them Sign This Form”

  1. Ursula Says:

    Fabulous…….simply fabulous!

  2. Ursula Says:

    I have also told my vets that under no circumstances are they to vaccinate my dogs and should my dog ever be vaccinated without my consent I will file the appropriate complaints as well as institute legal charges. Then I say, “that being said, I really am a fun pet owner and a very cooperative one.” Then, give a stern look and say, however…….I meant every word of what I said regarding vaccines.

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