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
* 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 MR
* 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 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: ______________________