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

4302320161_2a0ea8af81_zBy: Dave Mihalovic,
Prevent Disease.

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 by not providing informed consent; and second, many of them realize after their own extensive research that the risks are not worth the 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 have so far declined to sign this form.

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

I (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 blood

and, 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.

Dave Mihalovic is a Naturopathic Doctor who specializes in vaccine research, cancer prevention and a natural approach to treatment

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130 Responses to "You Want To Vaccinate My Child? No Problem, Just Sign This Form"

  1. Michael Cook  August 12, 2013 at 2:33 pm

    Never in the history of the human family has there been a system of health care as there are now, especially across the industrialised world. Never in the history of mankind has there been as many plagues or as many people sick with a plethora of diseases as there are today that are infecting hundreds of millions across continents and have been killing those same millions for decades. Plagues of the past came and went, infecting one particular land or continent and disapppearing as quickly as it came. Now we have plagues established in stone across the globe that have become acceptable to many people’s as though they were a natural part of life. Most of the modern day plagues are not of the outward contagious type, but the more subtle, and just as deadly, eroding the individuals health through “natural” means, i.e. the water supply, the food supply, the air we breath, even by the “medicines” that are supposed to protect us. All these modern day plagues go against those pattern of plagues of the previous millenia. It all points to a well thought out sophisticated agenda to terminate millions so subtly and acceptably as to make it a normal part of life. That mental indoctrination of acceptance is a sickness in itself and shows how far mankind has capitulated to the powers that be, and have abdicated our own responsibility for our own health and handed that responsibility to others.

  2. Dr. Clue.  August 13, 2013 at 9:50 pm

    VERY useful form. It helps physicians know when they’re dealing with uneducated and misinformed parents, not to mention fringe nutjobs. If these parents know so much about medicine, why do they take their kids to a doctor at all? Do your medicine at home. I’m sure your internet research will take care of everything.

    • Ameen  August 23, 2013 at 12:39 pm

      That Dr. Clue was a WELL PHRASED, HIGHLY EDUCATED AND UNBIASED SELF-CRITICAL answer. It misses also any sentiment of polemics since you added the PhD before exhibiting that blind consent to the divine lab coats will lead to a better, serene and happily during rather young years decaying life. You know so much about parents who research medicine as your paycheck allows. Splendid. Your comment actually deserves removal for the lunacy that combines with your low forehead, but we do not want to offend low foreheads. They can be jolly good people if they are not corrupted by corporate funding.

    • Peter Mullen  August 25, 2013 at 8:18 pm

      You are right, Doc… some fringies get so far out they forget humans can reason and medicine was not intended to kill. Of course, some will just insult you, as in the case of Yameen.

  3. Peter Mullen  August 25, 2013 at 8:15 pm

    Sorry to read this crap on an otherwise excellent website… science deniers are dooming kids to diseases that can be controlled. Naturopath= KOOK.

  4. michelle  August 26, 2013 at 1:50 am

    sooo, what do you do when you’re child hasn’t been vaccinated and therefore can’t start school?

  5. Kayla  September 16, 2013 at 12:41 pm

    Here are the side effects of vaccines:

    That your child will have a greatly reduced risk of dying from diseases like typhoid and the flu.
    That your child will not suffer from varicella (chicken pox), which alone can be harmless, but combined with another illness or immunocompromise can often be deadly.
    That they will never suffer from the reoccurence of varicella in the form of extremely painful shingles
    That they may never contract the forms of HPV that cause cervical cancer in many women.
    That they will not suffer from measles, mumps or rubella.
    That they will not die from small pox, which at one point was a leading cause of child deaths.
    That they will not develop liver disease or liver cancer from hepatitis.
    That they will not contract or spread the very quick and deadly form of bacterial meningitis, which is very common in schools and colleges.
    That they will not suffer and die from diseases like Diphtheria, Tetanus and Pertussis.
    That they will never become paralyzed from polio.

    If you would like to continue falsely believing that vaccines cause autism (which it doesn’t:, then go ahead. But not vaccinating your children is irresponsible and ignorant. You are putting your child and his or her peers at risk for contracting these any of these diseases, which are completely avoidable.

    Also, to those of you who don’t vaccinate your children, thank you for being of the same mindset that led to the 8 recent measles breakouts in non-vaccinating communities.


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