Vaccine safety assurance form

Source: Timothy Kirckof

When you are asked to sign a refusal form for vaccines, stating you're endangering your child and others, ask them to sign this.

Tell them you'll vaccinate with their signature.

Bet they back right off.

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 _____________________________________________________________

INT____

I am aware that vaccines typically contain many of the following fillers and adjuvants;

* 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
* 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.)

INT____

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 basis 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 basis 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 which oppose my own 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 Contrary Scientific Opinions."

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 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, or any other legal immunities from liability lawsuits in this case.

INT____

I agree to the statements made in this document of my own free will after consultation with competent legal counsel on this the ____ day of ______, _____(year) in the City of ______________, in the State/Province/Territory of ________________, ________________.

Physician Signature Signature of Legal Counsel

_______________________________ _________________________________

Witness Commissioner for Oaths

_______________________________ _________________________________

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Vaccine safety assurance form

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