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Out Of Mind » THE INSANITY OF REALITY » VACCINE TRUTHS: MEDICAL INDUSTRY LIES » Vaccinations: A Vaccine Form You Can Give to Your Doctor

Vaccinations: A Vaccine Form You Can Give to Your Doctor

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Vaccinations: A Vaccine Form You Can Give to Your Doctor

Medical Declaration of Inoculating

(Material only for these people with kind of aversion against vaccinations or compulsions in general for certain reasons)
'Your ...' MD ... or vaccinator probably will not sign this form, so
this it can still be an interesting experience or a salutary lesson for

addition to the common market- practice and the product package inserts,
admissions by various pharmaceutical corporations (if at all still in
use ...) to meet a 'patient' who is concerned about the responsibility
of the ingredients and so, vaccinations itself.

Concentrate aware of his re-action !

Neither the doctor nor the vaccine manufacturers to take responsibility for vaccine damage !

However this form gives you a sense of security.
when you become compelled to contaminate your body or your children
with proven toxic and proven to be highly hazardous substances.

You recognize the policy of fear - and fear-mongering of the pharmaceutical cartel.

As you now continue lies in your own discretionary.

You may alter the form any time and adopt your countries requirements, therefore, I recommend downloading the .doc format - it can be edited easily.

You may download the vaccineform to your machine and share with your email contacts in two different forms - .pdf or .doc




- Parsifal

Info from the article:

Want assurances from your physician or pediatrician about vaccines?

a form designed by Ken Anderson you can give to any doctor for filling
out - although there is probably no physician anywhere on earth who will
sign it.

As a divinely souled man or woman, you are not required to contract with *anyone* against your will.

Once we really get this, their jig is indeed up.

Take your power back.

Physician’s Warranty of Vaccine Safety

(Physician’s name, degree)_________________________, _____ am a
physician licensed to practice medicine in the State/Province of
________________, in the country of _________________.

State/Province license number is _______________ , and (if in the USA)
my DEA number is _______________. My medical specialty is

have a thorough understanding of the risks and benefits of all the
medications that I prescribe for or administer to my patients.

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 ___________________________________________
Risk Factor ____________________________________________
Vaccination ___________________________________________
Risk Factor ____________________________________________
Vaccination ___________________________________________
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 (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, and
* washed sheep red blood

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.

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.)

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”).

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

STEPS TAKEN: ______________________________________________________

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.

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.)

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.”

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”

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

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.

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.

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.

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.

following scientific studies have been performed to demonstrate the
safety of the Hepatitis B vaccine in children under the age of 5 years.


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”

am issuing this Physician’s Warranty of Vaccine Safety in my
professional capacity as the attending physician to (Patient’s name)

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.

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/Province of

__________________________________ (Name of Attending Physician)
__________________________________ L.S. (Signature of Attending Physician)
Signed on this _______ day of ______________ A.D. ________
Witness: _______________________________ Date: _____________________
Notary Public: ___________________________Date: ______________________

Image courtesy of © 2011 Thinkstock

more info on mandatory vaccinations:

Thanks to:


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