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You Want To Vaccinate My Child? No Problem, Just Sign This Form

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I have yet to meet a Physician that will sign this form now downloaded by hundreds of parents. The reason they won’t sign is two-fold: First, they do not want to place themselves in a vulnerable position of being negligent for not providing informed consent to thousands of other parents; and second, many of them realize after their own extensive research that the risks far outweigh any benefits when it comes to vaccination.

It’s been over a year since hundreds of parents have downloaded this form and there are still no reports of any signatures. Many physicians won’t even look at the form while they dismiss a parent’s anti-vaccination stance as ridiculous. The behavior is a clear indication of a very misinformed Physician who does not have his or her patient’s best interests at heart. They are not willing to inform their patients of the risks, only the benefits they feel are acceptable. They are not open-minded to any other side of the debate except their own biased view passed down through the medical system.

Then are those Physicians who have questioned the vaccination schedules and will pursue their own research. Many of them are now awakening themselves thanks to ongoing research and pressure from parents and even other colleagues to look at other perspectives besides their own indoctrination. If you are pressured by any Physician to vaccinate, please download and print this form (and send us a Physician signed copy if possible). Assertively state to your Doctor that it is the only way you will fully informed to consider vaccination, and that an analyses of the risks and benefits will better allow you evaluate the decision.

100% of Physicians approached with this form have so far declined to sign it.

Physician’s Warranty of Vaccine Safety Form

The following form was adapted from Ken Anderson’s original.

Download PDF English
Physician’s Warranty of Vaccine Safety

Download PDF Espanol
Garantia Medica para la Seguridad en las Vacunas

Download PDF Francais
Formulaire a faire signer (Vaccins)

PHYSICIAN’S WARRANTY OF VACCINE SAFETYI (Physician’s name, degree)_______________, _____ am a physician licensed to practice medicine in the State/Province of _________. My State/Provincial 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 __________________________I am aware that vaccines may contain many of the following chemicals, excipients, preservatives and fillers:* aluminum hydroxide
* aluminum phosphate
* ammonium sulfate
* amphotericin B
* animal tissues: pig blood, horse blood, rabbit brain,
* arginine hydrochloride
* dog kidney, monkey kidney,
* dibasic potassium phosphate
* chick embryo, chicken egg, duck egg
* calf (bovine) serum
* betapropiolactone
* fetal bovine serum
* formaldehyde
* formalin
* gelatin
* gentamicin sulfate
* glycerol
* human diploid cells (originating from human aborted fetal tissue)
* hydrocortisone
* hydrolized gelatin
* mercury thimerosol (thimerosal, Merthiolate(r))
* monosodium glutamate (MSG)
* monobasic potassium phosphate
* neomycin
* neomycin sulfate
* nonylphenol ethoxylate
* octylphenol ethoxylate
* octoxynol 10
* phenol red indicator
* phenoxyethanol (antifreeze)
* potassium chloride
* potassium diphosphate
* potassium monophosphate
* polymyxin B
* polysorbate 20
* polysorbate 80
* porcine (pig) pancreatic hydrolysate of casein
* residual MRC5 proteins
* sodium deoxycholate
* sorbitol
* thimerosal
* tri(n)butylphosphate,
* VERO cells, a continuous line of monkey kidney cells, and
* washed sheep red bloodand, 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 thimerosal 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: ______________________

I’m really anxious to hear back from any readers whose doctor decides to sign this document in an effort to satisfy your peace of mind. I also have a lengthy list of legal professionals who are very curious as well.


Philosophers stone – selected views from the boat


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    Total 20 comments
    • Freedom

      Just remember you can make a NOTICE like this for just about anything the government, police , or any other otheritative body is trying to coherce you into . You want a blood , urian , DNA sample you created all those thing, there for your property and if anybody wants your property you can charge what ever price you want for it .

    • JLXC

      After some basic easy fact checking on the side effects alone of vaccines it became obvious that they were terrible. Add in the eugenics crowd backing them and wow, serial muderers disguised as doo gooders or geeks. Terrible.

      • Anonymous

        5 1/2 month-old infant dies after 8 vaccines IN ONE DAY—> ‘SIDS’ Put On Death Certificate

        Then the hospital refuses to issue an autopsy report!

    • Man

      So the reasoning behind this is that you want to vaccinate your child with the result that…..?

      If a child does have some kind of effect…. the accuser in court still needs to prove it is by the vaccines…. the document does

    • DefaOmega

      They probably won’t sign this because of the false list of ‘ingredients’. Guys, you apparently haven’t heard yet but vaccines are mostly safe. They certainly don’t cause autism, which has been proven time and time and time and time again. Aside from some odd interactions and the occasional allergy there is nothing wrong with vaccines. I realize this goes against what the homeopathic doctors that are profiting from you want you to believe, but it’s the truth. There is no reason in 2015 that we should still be seeing Measles in the U.S. but when you have some people that think they’re ‘doing the right thing’ and leaving their children unprotected then things happen.

      Good Luck.

      • Anonymous

        Where’s your evidence that vaccines are safe? And where’s your proof that measles kill?

        • DefaOmega

          There is an absolutely absurd amount of information available about the safety of vaccines, I’m sure you are capable of finding it. I, as a general rule, do not post links to websites. As I’m always called a shill I don’t want to seen as a promoter of any company or website.

          I’m not sure if you actually expected resources for every vaccine or what but this should help you get started. Here’s a one based on the Quadrivalent human papillomavirus recombinant vaccine So essentially the death rate, assuming every reported death was caused by the vaccine, is 32 deaths in approximately 57,000,000 doses or one (1) death in 1.8 million doses.

          I also never stated that measles kills. Perhaps you should pursue furthering your reading comprehension skills and critical thinking. If you would like further schooling please let me know, I would be more than happy to further educating.

          Good Luck.

      • Nancy636

        The polio vaccine was not safe for me and thousands of others. Now I am really feeling the results as I get older. Easy to say if you are unaffected. B Gates said, if we get vaccines right we can effect the world population. Not exact quote but what did he mean by that? I heard him say it and I am intelligent enough to realize what he said was not right.

        • DefaOmega

          See it’s statements like this that lead me to believe you are lying. There are a reported 758 cases world-wide of polio coming from the Polio Vaccination and these are all from the vaccine entering new hosts have being excreted from the previous host due to poor sanitation enough times that the vaccine mutated.

          What Bill Gates actually said was along the lines of: by decreasing childhood mortality and improving healthcare world wide we could stabilize the world population. Essentially, Mr. Gates thinks that vaccines and better healthcare will overall reduce the growth of population because people will have fewer children when they expect them to survive.

          Good Luck.

      • NWO for Dummies.

        Please take all the vaccines yourself and die already.

    • Nancy636

      I got polio from the vaccination so this subject is a real problem for me. They are dangerous, but heck as long as everyone doesn’t get it. I am sure that is what some will say. What if it is your child? Not such an easy statement now, is it?

      • DefaOmega

        You are insanely unlucky and also must have lived in some truly disgusting setting to acquire polio from the vaccine. 758 cases of polio from the vaccine and over 10 Billion total doses. Yes it’s an easy statement and an easy call for anyone to make. No they are not dangerous, at least not in any statistically significant way.

        • NWO for Dummies.


        • ezrapound

          I guess we need to discount all those injured victims who were awarded money through the vaccine injury compensation program, where the government has admitted through court decisions that vaccines cause autism. Or the doctors who admitted to administering polio vaccines containing simian cancer. Or the law firms who make a fortune representing vaccine injury victims. Or even the simple fact that adjuvants like mercury are not safe in anyamount. Polio has been renamed guillann barre syndrome, chinese paralytic syndrome, as wel aseptic meningitis. Doctors and scientists rename diseaes when they don’t work, which is all the time. In fact, vaccines have never worked, thats the sad truth. I would hope you would have some shred of guilt after shedding your vaccinate induced sickness to others. Either defaomega is an imbecile or a troll, if hes a troll then that would also make him an imbecile.

    • The Clucker

      With the right vaccine regiment you can turn into the increadible hulk.

    • Mike Rotchurts

      I think you are asking the doctor to comment on things he is not an expert in, such as the chemistry in the pills or vaccines, so with honesty in mind I would tend to agree with them in refusing to sign a form stating they know what is in it down to a certain level. Doctors are only feed the information of the medication from the suppliers and what they can personally research themselves.

      • Karen

        Mike you have just hit the nail on the head and you can’t even understand it, haha even though it is words out of your own mouth. A doctors knowledge is only as good as what he researches…..everything else is simply what he learns in medical school. Just because he was told something – does not make it true… Not sure if you know but humans once believed the world was flat…there was a fear that you would ‘sail off the edge of the world’. This believe was held for some time – who gave the people this information?? Yet everyone believed it until a few chose to challenge ‘the powers that be’. People who choose to research vaccination are to be applauded – I for one will never follow blindly like a sheep, especially when it comes to my children. So I am sorry but you are wrong – a doctor should know exactly what is in a vaccine. He is asking me to inject something directly into my child’s blood stream, I for one want to know the hell what is in it down to every ingredient and what it can do to my child….but hey maybe you are not as protective as your children as I am. Also just because a doctor tells you something is safe does not mean it is. My parents generation were prescribed a ‘harmless’ (as told by God…i.e a doctor) morning sickness pill – Thalidomide….if you don’t know about this, do some reasearch and find out what happens when society tell you a drug is safe. I am sure thousands and thousands of parents who were effected by this drug with babies born with defects (half of which only survived) take with a grain of salt what doctors tell you are safe.

    • tom

      just wondering if the people that do not vaccinate are willing to put there children in a school where none of the children are vaccinated, and if they do, will they leave their child in their if lets say a child has contracted the measels or whooping cough? Will they let their children play with sick children. Just wondering how many parents who do not want to vaccinate would put their kids in these schools. Please let me know i am genuine curious.

      • Karen

        Yes Tom – I would feel more than safe putting my child in a school where no kids have been vaccinated. Also to answer your question – I would probably take my child out if there was an outbreak….whether my child was vaccinated or not. As you may or may not know – vaccinated kids get the deceases too so anyone could get it.

        Also as you are curious, are you aware that it is the vaccinated that spread most of these deceases? They are carriers in two ways. Those who have been vaccinated with a live virus vaccines such as MMR (measles, mumps and rubella), rotavirus, chicken pox, shingles and influenza can shed the virus for many weeks or months afterwards and infect the vaccinated and unvaccinated alike. This is not heresay….scientific evidence backs this up.

        Secondly although they may not have been recently vaccinated – they could get the decease itself (another thing that is ‘scientifically proven’…those doctors will tell you image how bad they would get it if they were not vaccinated…what a joke). As I was saying a vaccinated person can carry the decease and infect others whilst displaying no symptoms of a disease.

        So in all honestly I would feel feel safer if my kids were in a school of unvaccinated as opposed to vaccinated….they have a lot more to fear from the vaccinated…after all should not the vaccinated by SAFE?

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