Physicians Warranty of Vaccine Safety

I (Physicians name, degree)_________________________, _____ am a physician licensed to practice

medicine in the Province of ________________. My College of Medical Physicians license number is
_______________ . My medical specialty is ________________________
I have a thorough understanding of the riss and benefits of all the medications that I prescribe for or
administer to my patients. In the case of (Patients name) ___________________________ , age
_________ , !hom I have e"amined, I find that certain ris factors e"ist that #ustify the recommended
vaccinations. $he follo!ing is a list of said ris factors and the vaccinations that !ill protect against them%
&is 'actor ____________________________________________
(accination ___________________________________________
&is 'actor ____________________________________________
(accination ___________________________________________
&is 'actor ____________________________________________
(accination ___________________________________________
&is 'actor ____________________________________________
(accination ___________________________________________
&is 'actor ____________________________________________
(accination ___________________________________________
&is 'actor ____________________________________________
(accination ___________________________________________

I am a!are that vaccines typically contain many of the follo!ing fillers%
) aluminum hydro"ide
) aluminum phosphate
) ammonium sulfate
) amphotericin *
) animal tissues% pig blood, horse blood, rabbit brain,
) dog idney, money idney,
) chic embryo, chicen egg, duc egg
) calf (bovine) serum
) betapropiolactone
) fetal bovine serum
) formaldehyde
) formalin
) gelatin
) glycerol
) human diploid cells (originating from human aborted fetal tissue)
) hydroli+ed gelatin
) mercury thimerosol (thimerosal, Merthiolate(r))
) monosodium glutamate (M,-)
) neomycin
) neomycin sulfate
) phenol red indicator
) pheno"yethanol (antifree+e)
) potassium diphosphate
) potassium monophosphate
) polymy"in *
) polysorbate ./
) polysorbate 0/
) porcine (pig) pancreatic hydrolysate of casein
) residual M&C1 proteins
) sorbitol
) tri(n)butylphosphate,
) (2&3 cells, a continuous line of money idney cells, and
) !ashed sheep red blood
and, hereby, !arrant that these ingredients are safe for in#ection 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 a!are that some vaccines have been found to have been contaminated !ith ,imian (irus 4/ (,( 4/),
as reported by the Centre for 5isease Control, and that ,( 4/ is causally lined by some researchers to
non67odgin8s lymphoma and mesotheliomas in humans as !ell as in e"perimental animals. I hereby
!arrant that the vaccines I employ in my practice do not contain ,( 4/ or any other live viruses.
(9lternately, I hereby !arrant that said ,(64/ virus or other viruses pose no substantive ris to my
patient.)
I hereby !arrant that the vaccines I am recommending for the care of (Patients name)
_____________________ do not contain any tissue from aborted human babies (also no!n as 8fetuses8).
In order to protect my patients !ell being, I have taen the follo!ing steps to guarantee that the vaccines
I !ill use !ill contain no damaging contaminants.
,$2P, $9:2;% ______________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

I have personally investigated the reports made to the (92&, ((accine 9dverse 2vent &eporting ,ystem)
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 1 years.
$he bases for my opinion are itemi+ed on 2"hibit 9 , attached hereto, 66 8Physicians *ases for
Professional 3pinion of (accine ,afety.8 (Please itemi+e each recommended vaccine separately along
!ith the bases for arriving at the conclusion that the vaccine is safe for administration to a child under the
age of 1 years.) $he professional #ournal articles I have relied upon in the issuance of this Physicians
<arranty of (accine ,afety are itemi+ed on 2"hibit * , attached hereto, 66 8,cientific 9rticles in ,upport
of Physicians <arranty of (accine ,afety.8
$he professional #ournal articles that I have read !hich contain opinions adverse to my opinion are
itemi+ed on 2"hibit C , attached hereto, 66 8,cientific 9rticles Contrary to Physicians 3pinion of (accine
,afety.8
$he reasons for my determining that the articles in 2"hibit C !ere invalid are delineated in 9ttachment
5 , attached hereto, 66 8Physicians &easons for 5etermining the Invalidity of 9dverse ,cientific
3pinions.8
Hepatitis B
I understand that =/ percent of patients !ho are vaccinated for 7epatitis * !ill lose detectable antibodies
to 7epatitis * !ithin >. years. I understand that in >??= only 14 cases of 7epatitis * !ere reported to the
C5C in the /6> year age group. I understand that in the (92&,, there !ere >,/0/ total reports of adverse
reactions from 7epatitis * vaccine in >??= in the /6> year age group, !ith 4@ deaths reported.
I understand that 1/ percent of patients !ho contract 7epatitis * develop no symptoms after e"posure. I
understand that A/ percent !ill develop only flu6lie symptoms and !ill have lifetime immunity. I
understand that ./ percent !ill develop the symptoms of the disease, but that ?1 percent !ill fully recover
and have lifetime immunity.
I understand that 1 percent of the patients !ho are e"posed to 7epatitis * !ill become chronic carriers of
the disease. I understand that @1 percent of the chronic carriers !ill live !ith an asymptomatic infection
and that only .1 percent of the chronic carriers !ill develop chronic liver disease or liver cancer, >/6A/
years after the acute infection.
$he follo!ing scientific studies have been performed to demonstrate the safety of the 7epatitis * vaccine
in children under the age of 1 years.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
In addition to the recommended vaccinations as protections against the above cited ris factors, I have
recommended other non6vaccine measures to protect the health of my patient and have enumerated said
non6vaccine measures on 2"hibit 5 , attached hereto, 8;on6vaccine Measures to Protect 9gainst &is
'actors.8
I am issuing this Physicians <arranty of (accine ,afety in my professional capacity as the attending
physician to (Patients name) ________________________________.
&egardless of the legal entity under !hich I normally practice medicine, I am issuing this statement in
both my business and individual capacities and hereby !aive any statutory, Common Ba!, Constitutional,
CCC, international treaty, and any other legal immunities from liability la!suits in the instant case.
I issue this document of my o!n free !ill after consultation !ith competent legal counsel !hose name is
_____________________________, an attorney admitted to the *ar in the Province of ______________

__________________________________ (;ame of 9ttending Physician)
__________________________________ B.,. (,ignature of 9ttending Physician)
,igned on this _______ day of ______________ 9.5. ________
<itness% _______________________________ 5ate% ______________________
;otary Public% ___________________________ 5ate% ______________________