Vaccine safety physician form

By Cynthia A. Janak

I was given a form by an acquaintance of mine for the doctor to fill out in regards to vaccinations. I found it to be very well written and a must for every parent or guardian to submit to their physician. The author of this document is unknown but I want to thank them from the bottom of my heart for the hard work to create this excellent form.

If you consider that a child receives over 40+ vaccinations before the age of five and the reports of adverse reactions like autism, it is important to know that your family doctor believes that the vaccines that he or she is injecting into that little arm are safe.

Below is a reproduction of that form. Please copy and paste to a word document for your own use. (PDF available here.)

My prayers are with you and your family.

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Physician's Warranty of Vaccine Safety
(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:

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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 Thermosol
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
Sucrose
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. Reports to the contrary, such as reports that mercury thermosol causes severe neurological and immunological damage, are not credible. I am aware that some vaccines have been found to have been contained with Simian Virus 40 (SV-40) and that SV-40 is casually linked by some researchers to non-Hodgkin's lymphoma and mesotheliomas in humans as well as in experimental animals.

I hereby give my assurance that the vaccines I employ in my practice do not contain SV-40 or any other live viruses. (Alternately, I hereby give my assurance that said SV-40 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 cells 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:
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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% 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% of patients who contract Hepatitis B develop no symptoms after exposure. I understand that 30% will develop only flu-like symptoms and will have lifetime immunity.

I understand that 20% will develop the symptoms of the disease, but that 95% will fully recover and have lifetime immunity. I understand that 5% of the patients who are exposed to Hepatitis B will become chronic carriers of the disease. I understand that 75% of the chronic carriers will live with an asymptomatic infection and that only 25% of the chronic carriers will develop chronic liver disease or liver cancer, 10-30 years after the acute infection. The following studies have been performed to demonstrate the safety of the Hepatitis B vaccine in children under the age of 5 years.

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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 y 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 herby waive any statutory, Common Law, Constitutional, UCC, international treaty, and any other legal communities 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 ________________________________.

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Name of Attending Physician

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L.S. (Signature of Attending Physician)

Signed on this _______________ day of ____________________ A.D. ________________

Witness: _____________________________________ Date: ________________________


Notary Public: ________________________________ Date: ________________________

© Cynthia A. Janak