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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)butylphosphat e,
. 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: ____________ _________ _________ Date:
____________ _________ ___
Love, Gabby. :0)
"I know of nobody who is purely Autistic or purely neurotypical. Even God had some Autistic moments, which is why the planets all spin." ~ Jerry Newport
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