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 __________________________________________________________

2

I am aware that vaccines typically contain many of the following fillers:

aluminum hydroxide aluminum phosphate

ammonium sulfate amphotericin B

calf (bovine) serum animal tissues: pig blood, horse blood, rabbit

brain, dog kidney, monkey kidney, chick

embryo, chicken egg, duck egg

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

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”).

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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.

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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: ______________________











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