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A Vaccine Form - Physician's Warranty of Vaccine Safety
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A Vaccine Form - Physician's Warranty of Vaccine Safety 8 years, 8 months ago #1229

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A Vaccine Form - Physician's Warranty of Vaccine Safety

03.03.2009, Mercola.com


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 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 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: ______________________




Dr. Mercola's Comments:


Although you likely won’t find any physician anywhere willing to sign this form, it could be a valuable learning lesson to simply bring it with you and present it to him or her, if nothing else just to observe the reaction.

Because the truth is, your pediatrician is not taking responsibility for any adverse reactions or damage that happens to your child, and neither are the pharmaceutical companies that manufacture the vaccines that injure countless children each year.

Vaccine companies have long ago used political manipulation through their strong lobbying efforts to created legislation that essentially immunizes them against any law suit damages or awards. The Homeland Security bill also contains a provision that protects manufacturers of vaccines that contain thimerosal from liability in vaccine-related lawsuits. Pro-vaccine-safety educators have long been saying that vaccines can over-stimulate your child’s immune system, sometimes causing the very disease it’s designed to protect against, or worse. And, when several vaccines are administered together, or in close succession, their interaction may completely overwhelm your child’s developing immune system.

Once that happens, what can you do? Where can you turn?

You’re far better off doing your own research beforehand so that you can make an educated decision about the health of your child, than to blindly trust your pediatrician, who likely has not done much research on it either, and is in turn trusting the information they get directly from the vaccine manufacturer.

There’s Little Help to Be Had Once Tragedy Strikes

President Reagan signed the National Childhood Vaccine Injury Act of 1986 into law on Nov. 14, 1986, which is the legislation I mentioned above. However, in the two decades since, it has become obvious that the vaccine injury compensation program is fatally flawed, and so broken it should be repealed – something Barbara Loe Fisher of the National Vaccine Information Center (NVIC) is strongly advocating.

The NVIC is also currently petitioning the Obama Administration and Congress to investigate the fast track licensure and universal use recommendation of Gardasil; the HPV vaccine that has already caused over 10,000 adverse event reports to be filed since its release in 2006.

During the program’s 22-year history, two out of three individuals applying for federal vaccine injury compensation have been turned away empty-handed.

As of October 2008, of a total of 12,746 claims that had been filed, 2,266 had been compensated to the tune of about $1.8 billion, while 4,755 had been dismissed.

And although the claims were supposed to be handled "quickly, easily and with certainty and generosity," according to a House report accompanying the 1986 legislation, many claims have taken years -- more than 10 years -- to be settled.

Even the U.S. Health Resources and Services Administration state that it takes an average of two to three years to adjudicate a claim after it is filed.

How Does the Vaccine Injury Compensation Program Work?

Prior to October 1, 1988, you could pursue an unrestricted lawsuit against a vaccine manufacturer if you, or your child were injured by a vaccine. After that date, including currently, you are required to apply for federal compensation prior to pursuing a lawsuit.

According to the program’s guidelines:

The system will offer to pay up to $250,000 for a vaccine-associated death.
The system will offer to pay for all past and future unreimbursed medical expenses, custodial and nursing home care; up to $250,000 pain and suffering; and loss of earned income.

These remedies surely fall far short of what is deserved and required if your child is injured, or killed, by a vaccine. You simply cannot put a price on a lost life, and a study by Harvard professor Michael Ganz found that the lifetime cost of caring for a child with autism is more than $3 million.

And yet, according to statistics from the U.S. Department of Health and Human Services, not one case related to autism has been deemed “compensable.” Only last year did the government concede that vaccines “significantly aggravated” an underlying disorder and caused “autistic symptoms” in one 9-year-old girl named Hannah Poling.

So who is actually responsible for paying whatever meager compensations that do get awarded?

Contrary to what you would think, it is NOT the vaccine manufacturers.

The system is funded by a surcharge on each dose of vaccine sold. The doctors pay the tax initially when they purchase the vaccines, but this is passed right down to the parents of the child.

So not only are the vaccine manufacturers shielded from potential lawsuits, they are not even responsible for paying one cent of the claims filed against them -- you are!

What Options do You Have?

The government essentially forces children to get vaccines by threatening to not let them into the school system otherwise. Well, a growing network of parents have decided to homeschool their children, in part because of their belief that mandated vaccinations for public and private school children are a dangerous overreach by state governments.

The trend toward not vaccinating has been growing for some time now. Close to 70 percent of physicians say that the number of concerns from parents have increased significantly in recent years.

And rightfully so.

If you read the form above, you saw a long list of potentially toxic chemicals – fillers and adjuvants -- that are included in various vaccines given to newborns and children.

If your child is vaccinated according to the CDC's recommended schedule, by the time your child starts kindergarten he or she will have received 48 doses of 14 vaccines. Of these, 36 doses will be given during the first 18 months of life.

Public health officials have NEVER proven that it is indeed safe to inject this number and volume of vaccines into infants. What's more, they cannot explain why, concurrent with an increasing number of vaccinations, there has been an explosion of neurological and immune system disorders in American children.

As I’ve stated before, I’m not anti-vaccine, but rather pro-vaccine safety, and homeschooling your children is not the only option out there.

In the Related Links below, I have included the link to Dr. Donald Miller’s recommendations for a more sensible vaccination schedule.

If you have reviewed the evidence and still feel your child should be inoculated to a certain degree, this is a far safer alternative to the standard program. Your pediatrician will not like this schedule, but he or she will probably be more apt to go along with a modified schedule than signing the form above.

I’d also recommend you print out this NVIC flyer detailing how to recognize a vaccine reaction, and review it after each and every vaccination.

If you decide you do not want to vaccinate, know that all 50 states have vaccination requirements but all states provide exemptions for medical reasons while 48 states allow exemptions for sincerely held religious beliefs. Another 18 states allow parents to opt out for personal, conscientious or philosophical beliefs as well
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