Vaccines for Kids and Babies--Get the Doctor to Sign these forms

[Soroush Ebrahimi]

(If you get any doctor brave enough to sign such a form, please let me know!)

Consent for Administration of Vaccination

Dear Responsible Doctor:

If you will be administering a vaccination to me or my child today, I will
need you to complete the following consent form. Thank you.

I (physician's name) ____________ _________ __ do hereby state that I have
advised my patient (patient or child name) ____________ ________ and/or
parent of my patient (parent's name) ____________ _________ that in my
professional opinion this patient/child should be given the vaccination,
drug or other (name of vaccination/ drug/other) ____________ _________
_________ _________ _, manufacturer' s name ____________ _________ __,
serial number ____________ ___, batch number ____________ _________ _,
expiry date________ _________ __.

I have on this (day) _________ (month) _______ (year) _________ administered
this vaccination/ medication/ drug AFTER advising the above named
patient/parent of minor patient that there is little or no risk involved
with this vaccination, medication, drug therapy or treatment. I hereby do
agree that should this patient/child at any time suffer or develop any
permanent condition deleterious or injurious to his/her health as a result
of this treatment, I will pay for any and all costs involved related to the
care and treatment necessary for this patient/ child for the rest of his/her
natural life. I further agree that if my earnings are insufficient to meet
these costs, I will sell my home, my business and all material possessions
and put those proceeds towards meeting the patient-involved expenses.

Date: ____________ ______

Signature of responsible physician: ____________ ________

Signature of person administering vaccination/ medication/ drug:
____________ ________

Occupational title: ____________ _____

Witness (parent or other) ____________ ______

Physician's Warranty of Vaccine Safety

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:

____________ _________ _________ _________ _________ _________ _

____________ _________ _________ _________ _________ _________ _

____________ _________ _________ _________ _________ _________ _

____________ _________ _________ _________ _________ _________ _

____________ _________ _________ _________ _________ _________ _

____________ _________ _________ _________ _________ _________ _

____________ _________ _________ _________ _________ _________ _

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 ..
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)butylphosphat e, .. 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
thimerosol causes severe neurological and immunological damage, 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 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:

____________ _________ _________ _________ _________ _________ _

____________ _________ _________ _________ _________ _________ _

____________ _________ _________ _________ _________ _________ _

____________ _________ _________ _________ _________ _________ _

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:

____________ _________ _________ _________ _________ _________ _

____________ _________ _________ _________ _________ _________ _

____________ _________ _________ _________ _________ _________ _

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: ____________ _________
___