The Form You Should Get your Dr. To Sign I ………………(Physicians name)…………………. do hereby state I have advised the parent(s) of ............(Childs name)……........that
in my professional opinion the child should be given ………(Vaccine's name)………….include manufacturer name, serial
#…………, batch#……….….I have this day ...…(mm/dd/yy) ……………. administered this medication after advising the parents
that the child is at little or no risk from the treatment. I hereby do agree to take full responsibility should the child at any time suffer or develop any permanent condition deleterious or injurious to their health as a result of this treatment. I will pay any and all costs relating to the care and treatment of this 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 to put the proceeds towards meeting these costs.
............................................ witness: Parent or other
Signature of physician
Or this wonderful letter by Jim.....if it distorts in any way send me and email and I'll send you a word document of it.
To: (Physician or Health Care Professional's Name)
(Your Employer or Government Agency Name)
Re: Personal Affidavit and Warranty of Vaccine Efficacy and Safety
Dear Responsible Doctor or other Designated Health Care Professional,
If you will be administering a vaccination to me today, I will need you to complete the following form. Thank you.
Physician or Health Care Professional's Attestation and Warranty of Vaccine Efficacy and Safety
I, (Physician or Health Care Professional's name, degree)____________________, ___________ am a (physician/health care) professional licensed to practice medicine in the State of ____________.
My State license number is _________________, and my DEA number is __________________. My medical specialty is _____________________________.
I do hereby state that I have advised my patient (Your Name), that in my professional opinion this patient should be given the vaccination(s), drug(s) or other (name of vaccination(s)/drug(s)/other) ________________________, manufacturer's name ________________________, serial number ___________________,
batch number _____________________, expiry date____________________.
I have on this _________day of ___________________(month), A.D._________(year),
administered this vaccination/medication/drug AFTER advising the above named patient that there is no risk involved with this vaccination, medication, drug therapy or treatment to the good health of my patient whatsoever. Therefore, and because any potentially negative or adverse effects of said vaccine(s) are apparently (and contradictorily) no longer insurable as being too high a risk, I hereby agree, without reservation, that should this patient at any time suffer or develop any permanent condition deleterious or injurious to my patient's health as a result of this treatment, I will personally pay for any and all costs involved relating to the care and treatment necessary for this patient 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 of my material possessions and put those proceeds towards meeting the patient-involved expenses. Furthermore, as the fully authorized, designated and currently employed representative of (Your Employer Name or Government Agency), and acting in that capacity under personal penalty of perjury, who has been granted complete and unconditional authority to contractually bind (Your Employer Name or Government Agency), under full acceptance of commercial liability, I do hereby bind as legally liable (Your Employer Name or Government Agency) for the lifelong medical and private care of the patient as well as all financial hardship incurred by the patient as a result of said deleterious or injurious effects of said vaccine(s), should they occur.
Page 1 of 4 Initials of Responsible Physician or Designated Health Care Professional: __________
I do hereby state that 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 (Your Name; age (??)), whom I have examined, I find that certain risk factors exist that justify the recommended vaccination(s).
Following is a list of said risk factors that the vaccination(s) will, without question, protect my patient from:
Risk Factor(s) Vaccination(s):
I am aware that vaccines typically contain many or all of the following substances:
aluminum hydroxide, human diploid cells,
hydrolized gelatin, (originating from aborted
aluminum phosphate, human fetal tissue),
ammonium sulfate, squalene,
amphotericin B, latex,
animal tissues, hydrolized gelatin,
pig blood, mercury (thimerosol),
horse blood, monosodium glutamate (MSG),
rabbit brain, neomycin, neomycin sulfate,
dog kidney, phenol red indicator,
monkey kidney, phenoxyethanol (antifreeze),
chick embryo, potassium diphosphate,
chicken egg, potassium monophosphate,
duck egg, polymyxin B, polysorbate 20,
calf (bovine) serum, polysorbate 80.,
betapropiolactone, porcine (pig) pancreatic,
fetal bovine serum, hydrolysate of casein,
formaldehyde, residual MRC5 proteins,
formalin, gelatin, sorbitol, sucrose,
glycerol, tri(n)butylphosphate, VERO cells,
sheep blood. retroviruses and/or carcinogenic or other forms of infectious mycoplasmic agents
Page 2 of 4 Initials of Responsible Physician or Designated Health Care Professional: __________
Furthermore, and not withstanding my patient's religious objections and medical concerns regarding the possible inclusion of scripturally unclean and possibly diseased animal remains as well as aborted human fetal tissues contained within the vaccine(s) in apparent direct violation of (Your Employer's Name or Government Agency) own ethical standards and corporate policy of No Harassment/Discrimination (page 58; paragraphs(s)1&2: “Associate Handbook”-example), as well as federal, state and international laws, treaties and conventions, or the extensive list of cautions and warnings of the very real possibility of severe adverse reactions as so listed on the vaccine manufacturer(s)' own package insert(s), or the high number of adverse reports against said vaccine(s) that have already been recorded worldwide, or the apparent complete absence of any verifiable and independent, peer reviewed, long term, double blind and placebo controlled in vivo studies confirming the safety and/or efficacy of said vaccine(s), or my patient's assertion that he/she has already been exposed to both this year's seasonal and Swine flu strains and has overcome them both with no difficulty or residual adverse effects whatsoever thereby having already been conferred long lasting and heightened immunity against said strains, and in spite of my patient's assertion of chemical sensitivity and/or allergies to numerous chemical and biological substrates, additives and adjuvants possibly contained within said vaccine(s) as well as the irrefutable fact that due to the proprietary nature of some ingredients, that those ingredients may not even be required to be listed on the package insert(s), thereby rendering as scientifically impossible a medically objective risk/benefit assessment on behalf of my patient, as well as my being totally unfamiliar with my patient's past medical history or unique and untested physiology, I nonetheless attest and warrant that these ingredients are effective and safe for injection or inhalation 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 personal assurance that the vaccine(s) I employ in my practice do not contain SV 40 or any other infectious agents and therefore pose no health risks to my patients whatsoever.
Furthermore, I hereby Attest and Warrant that the vaccine(s) I am recommending for the care of (Your 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 vaccine(s) I will use will contain no damaging contaminants. The steps taken are as follows:
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 vaccine(s) I am recommending are both effective and safe for administration to this patient, adverse reports notwithstanding.
I have now been made aware of the both the video from Sister Teresa Forcades, MD; PHD - “Bell Tolling for the Swine Flu” at: www.youtube.com/watch?v=61ySNSQTR-Q&feature=related, as well as the following quote by Dr. Anthony Morris, a distinguished virologist and former Chief Vaccine Officer at the U.S. Food and Drug Administration (FDA), who states that “There is no evidence that any influenza vaccine thus far developed is effective in preventing or mitigating any attack of influenza” and that “The producers of these vaccines know they are worthless, but they go on selling them anyway,” and hereby affirm that both doctors' assertions (as well as many others), regarding the vaccines' apparent lack of safety and efficacy are totally false and without merit.
The basis for my opinion is itemized on Exhibit A, attached hereto, "Physician or Health Care Professional's Basis for Professional Opinion of Vaccine Efficacy and Safety." (Please itemize each recommended vaccine separately along with the basis for arriving at the conclusion that the prescribed vaccine(s) are both effective and safe for administration to this patient).
The professional journal articles I have relied upon in the issuance of this Physician or Health Professional's Warranty of Vaccine Efficacy and Safety are itemized on Exhibit B, attached hereto, "Scientific Articles in Support of Physician or Health Care Professional's Warranty of Vaccine Efficacy and Safety." The professional journal articles that I have read which contain contradictory opinions to my own are itemized on Exhibit C,
Page 3 of 4 Initials of Responsible Physician or Designated Health Care Professional: __________
attached hereto, "Scientific Articles Contrary to Physician or Health Care Professional's Opinion of Vaccine Efficacy and Safety." The reasons for my determining that the articles in Exhibit C are invalid are delineated in
Attachment D , attached hereto, "Physician or Health Care Professional's Reasons for Determining the Invalidity of Adverse Scientific Opinions." I do therefore Attest and Warrant (and in spite of the overwhelming body of evidence to the contrary), that the vaccines that I am prescribing for my patient are hereby proven beyond question to be safe and effective for the condition(s) for which the said vaccine(s) are here being administered.
Regardless of the legal entity under which I normally practice medicine, I am issuing this statement in both my professional business or government capacity and as a private individual while hereby waiving any Statutory, Common, Equity, UCC, Maritime/Admiralty or Constitutional law, international treaty or 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 ___________________, as well as
________________________, Supervisor, Department Head, President, CEO, or Company Owner
(circle 1 or more titles) of (Your Employer or Government Agency).
Signature of Attorney. Signature of: Supervisor, Department Head, President, CEO or Company Owner
Printed Name of Responsible Physician or Designated Health Care Professional.
Signature of Responsible Physician or Designated Health Care Professional.
Printed Name of Witness.
Signature of Witness
Subscribed and Sworn before Me on this_______day of ____________________, A.D.__________.
Notary Public: _________________________________________,
County: _________________, State:___________________.
My Commission Expires: ____________________________________.
Page 4 of 4 Initials of Responsible Physician or Designated Health Care Professional: __________
If he refuses to sign this....Sign this for his files
REFUSAL OF RECOMMENDED VACCINES
Patient Name_______________________________ Birthdate_______________
As the parent/guardian of __________________________, I have investigated the risks and benefits of the following vaccines and diseases. I am aware that there are documented cases of people contracting diseases for which they are clinically fully immunized and that the manufacturers of the vaccines do not guarantee 100% efficacy. I am also aware that VAERS (Vaccine Adverse Events Reporting System) documented cases of over 54,000 adverse reactions from vaccines in a 20-month period. The National Vaccine Injury Fund, created in 1986 to compensate those damaged by vaccines has paid out over one billion dollars in compensation to date.
POLIO: I have been informed of the risk of my child developing paralytic disease and meningitis associated with poliomyelitis. I understand that even under epidemic conditions, natural polio produces no symptoms in over 90% of those exposed to it.(1) I understand that there have been no cases of wild polio in the US in the last 20 years and that those cases which have been documented have been caused by the vaccine.(2)
I understand the following side effects for the vaccine are possible:
Killed virus polio: temperature of *102° in up to 38%, sleepiness, fussiness, crying, decreased appetite, vomiting, Guillain-Barré Syndrome and allergic reaction in those allergic to neomycin, polymyxin B and streptomycin. Precautions include those who have had a previous negative reaction, pregnant women, and possibly those with HIV/AIDS or otherwise compromised immune systems.
Live virus polio: Reactions include contraction of polio by those who have received the virus and by those who have come into contact with body fluids and wastes of the immunized person. Paralytic symptoms may follow contraction of polio. Live virus is reportedly shed for up to 8 weeks after the inoculation. Guillain-Barré Syndrome has also been noted. Not recommended for use in households where someone has a compromised immune system, for pregnant women, or where a previous reaction has been reported.(3)
Killed virus Ipol® is grown on monkey kidney cells, contains formaldehyde, and triple antibiotics. Poliovax® is grown on cells from an aborted baby, contains formaldehyde, cow serum and triple antibiotic solution.(4) The monkey kidney cells used in the original killed polio vaccine contains SIV-40 and has been found in tumor cells of children whose parent's were vaccinated against polio using the contaminated virus.(5) The live vaccine is grown on monkey kidney cells, antibiotics and calf serum.
HEMOPHILUS INFLUENZAE B: I have been informed of the risk of my child developing meningitis (although this vaccine will not protect the child from meningitis from all other forms such as pneumococcus, and meningococcus, viruses, and fungi), pneumonia, and infections of the blood, joints, bone, and soft tissue associated with Hemophilus Influenzae B. I understand that this disease is most likely in children up to 15 months of age and is fatal in 3-6% of children who contract it. Incidence of this disease today is low and the vaccine has not proven to be highly effective in 41% of cases, according to some studies.(6) Treatment is available. The vaccine is often combined with the DPT which has the highest reaction rate of any vaccine available today. Reactions include: contracting HIB, localized pain, erythema and induration, fever >100.6°, irritability, lethargy, anorexia, rhinorrhea, diarrhea, vomiting, cough, when administered alone. Reactions occurred in up to 30% of patients. When administered in conjunction with the DPT, reactions include local tenderness erythema and induration, fever >100.8°, irritability, drowsiness, anorexia, diarrhea, vomiting, persistent crying, seizures, urticaria, hives, renal failure, Guillain-Barré Syndrome and death. Reactions occurred in up to 77.9% of patients.(7) The vaccine contains yeast, thimerosal (mercury derivative), and diphtheria toxoid when given alone.(8)
PERTUSSIS: I have been informed of the risk of my child developing whooping cough, pneumonia, convulsions, inflammation of the brain, and death associated with pertussis. I understand the disease is rarely fatal, with a 99.8% recovery rate. It is most serious and life-threatening in children under 6 months old, but there are adequate methods of treatment available.(9) The vaccine is most often given in conjunction with diphtheria and tetanus as the DPT or as the DaPT. Pertussis vaccine may cause: fevers >106, pain swelling, diarrhea, projectile vomiting, excessive sleepiness, high--pitched screaming, inconsolable crying bouts, seizures, convulsions, collapse, shock, breathing problems, brain damage and SIDS. One in 600 suffer a severe reaction in one study (10) and 1 in 875 suffered shock-collapse and convulsions.(11) Those in the 2nd study were only tracked for the first 48 hours following immunization. A more recent study indicates that 1 in 100 react with convulsions, collapse, or high-pitched screaming and 1 in 3 of those cases sustained permanent brain damage.(12) In a study of 103 children who died of SIDS, 70% died within 3 weeks of the DPT vaccine and 37% of those died within the first week.(13) The DaPT is recommended as a safer option for vaccination. Side effects of the DaPT were only tracked for 72 hours and included: tenderness, erythema, induration, fever >102.2°, drowsiness, fretfulness, vomiting, upper respiratory infection, diarrhea, rash, febrile seizures, persistent or unusual crying, lethargy, hypronic-hyporesponsive episode, urticaria, anaphylactic shock, convulsions, encephalopathy, mono- and polyneuropathies and death.(14) Not recommended for children under 15 months or for those who have not had 3 injections of the DPT. Either form of the vaccine contains thimerosal (mercury derivative), formaldehyde, and aluminum phosphate.(15)
DIPHTHERIA: I have been informed of the risk of my child developing paralysis, heart failure, or respiratory failure associated with diphtheria. I have also been informed that there have only been 5 cases reported annually since 1980.(16) I am also aware that diphtheria is rarely fatal and treated with antibiotics and bed rest. (17) The Diphtheria component is most often given within the DPT or DaPT and includes the same side effects and reactions as those listed for pertussis.
TETANUS: I have been informed of the risk of my child developing fatal neuromuscular disease related to tetanus. I understand that the incidence of tetanus is low, and there is an antitoxin, should we decline the
immunization. I understand that contracting tetanus does not provide life-long immunity, and neither does the vaccine. I understand that to prevent more severe reactions from the vaccine, the tetanus component has been so significantly "diluted" that it is clinically ineffective.(18) I understand that the death rate for properly treated cases of tetanus may be as high as 20%.(19) Side effects of the tetanus vaccine alone include: high fever, pain, recurrent abscess formation, inner ear nerve damage, demyelinating neuropathy, anaphylactic shock and loss of consciousness.(20) Tetanus given in the DPT or DaPT shot include the same side effects and reactions as those listed for pertussis.
RUBEOLA (MEASLES): I have been informed of the risk of my child developing pneumonia, encephalitis (inflammation of the brain), degenerative disease of the nervous system with convulsions (subacute sclerosing panencephalitis) related to rubeola. I understand the death rate for measles is .03 in 100,000.(21) I understand that since 1984, over 55% of documented, confirmed cases of measles have been in fully immunized persons.(22) I understand that the greatest risk of the measles vaccine may be to push the incidence of this disease into the late teens and adulthood where it is more likely to be fatal or cause more adverse and long-term effects.(23) The measles vaccine is a live vaccine, and carries the risk that it will cause the patient to contract measles. Other adverse reactions include: stinging or burning at the injection site, anaphylaxis, fever up to one month following injection, rash, cough, rhinitis, erythema multiforme, lymphadenopathy, urticaria, diarrhea, febrile convulsions, seizures, thrombocytopenia, purpura, vasculitis, optic neuritis, retrobulbar neuritis, papillitis, retinitis, encephalitis and encephalopathy, ocular palsies, Guillain-Barré Syndrome, ataxia, and subacute sclerosing panencephalitis.(24) Measles vaccine is most often given as a part of the MMR which includes the following side effects: burning or stinging at injection site, malaise, sore throat, cough, rhinitis, headache, dizziness, fever, rash, nausea, vomiting, diarrhea, erythema, induration, tenderness, lymphadenopathy, parotitius, orchitis, nerve deafness, thrombocytopenia, purpura, allergic reactions, urticaria, polyneuritis, arthralgia, arthritis, anaphylaxis, vasculitis, otitis media, conjunctivitis, febrile convulsions, seizures, syncope, erythema multiforme, optic neuritis, retrobulbar neuritis, papillitis, retinitis, encephalitis and encephalopathy, ocular palsies, Guillain-Barré Syndrome, ataxia, subacute sclerosing panencephalitis,(25) and a recent study from Europe indicates that there may be a link between the MMR (measles/mumps/rubella) vaccine and autism and irritable bowel syndrome.(26)
Measles vaccine contains chick embryo cells, neomycin, sorbitol and hydrolyzed gelatin. MMR contains all live vaccines, chick embryo, cells from aborted babies, neomycin, sorbitol and hydrolyzed gelatin.(27)
MUMPS: I have been informed of the risk of my child developing inflammation of the testicles, joints, kidneys, and/or thyroid, and hearing impairment related to mumps. I understand that mumps is rarely harmful in childhood, and that most of the above risks occur when mumps is contracted in adolescence or adulthood.(28) I understand that there is a Mumps vaccine which poses the following risks: contraction of mumps from the live vaccine, burning or stinging at the injection site, anaphylaxis, cough, rhinitis, fever, diarrhea, vasculitis, parotitis, orchitis, purpura, urticaria, erythema multiforme, optic neuritis, retrobulbar neuritis, syncope, encephalitis, febrile seizures, and nerve deafness.(29) Mumps is usually given in the MMR and may cause those side effects and adverse reactions as noted in the measles section above. Mumps vaccine is live and should not be given to pregnant women. It is cultured in chick embryos and contains sorbitol and hydrolyzed gelatin.(30)
RUBELLA (GERMAN MEASLES): I have been informed of the risk of my child developing inflammation of the brain or joints, and of the risk of birth defects (including eye defects, heart defects, deafness, mental retardation, growth failure, jaundice, and disorders of blood clotting) in infants born to mothers who contract rubella during pregnancy, related to rubella. Therefore, I understand that the greatest risk to my child may be if she never contracts rubella as a child, but when she is pregnant and it damages her unborn child. If she contract rubella in childhood, she is immune for life, and prior to the vaccine 85% of the population was immune.(31) I understand that if she is not immune as an adult, she can choose to take the vaccine prior to becoming pregnant. I understand that many of those who contract rubella have been immunized (up to 80%). (32) Adverse reactions from the vaccine among teenage girls is 5-10% and 30% in adult women.(33) Adverse reactions include: contracting rubella from the live virus in the vaccine, burning or stinging at the site, lymphadenopathy, urticaria, rash, malaise, sore throat, fever, headache, dizziness, nausea, vomiting, diarrhea, polyneuritis, arthralgia, arthritis, local pain and inflammation, erythema multiforme, cough, rhinitis, vasculitis, anaphylaxis, syncope, optic neuritis, retrobulbar neuritis, papillitis, Guillain-Barré Syndrome, encephalitis, thrombocytopenia, purpura, and Chronic Fatigue Syndrome. (34) Rubella is most often administered in the MMR and may cause those side effects and adverse reactions listed under measles. Rubella is cultured on the tissue of an aborted child. This child was the 27th child aborted and tested by researchers due to exposure to rubella in a pregnant woman. It contains neomycin, sorbitol and hydrolyzed gelatin.(35)
HEPATITIS B: I have been informed of the risk of my child developing Hepatitis B viral infection which can cause chronic inflammation of the liver leading to cirrhosis, liver cancer, and possibly death. I understand that my child's risk of developing Hepatitis B is low if I am not a carrier or infected, if my child does not engage in promiscuous sex or use drugs. I understand that there is antibiotic treatment for HepB and that most of those who contract it recover.(36) I understand that the HepB vaccine only contains strains of HepB and is not effective against HepA, C, D, E, F, or G. I understand that the HepB vaccine has the following side effect and adverse reactions: induration, erythema, swelling, fever, headache, dizziness, pain, prutitus, ecchymosis, sweating, malaise, chills, weakness, flushing, tingling, hypotension, flu-like symptoms, upper respiratory illness, nausea, anorexia, abdominal pain and cramping, vomiting, constipation, diarrhea, lymphadenopathy, pain or stiffness in muscles and joints, arthralgia, myalgia, back pain, rash, urticaria, petechiae, sleepiness, insomnia, irritability, agitation, anaphylaxis, angioedema, arthritis, tachycardia/palpitations, bronchospasm, abnormal liver function tests, dyspepsia, migraine, syncope, paresis neuropathy, hypothesis, paresthesis, Guillain-Barré Syndrome, Bell's Palsy, transverse myelitis, optic neuritis, multiple sclerosis, thrombocytopenia, eczema, purpura, herpes zoster, erythema modosum, alopecia, conjunctivitis, keratisis, visual disturbances, vertigo, tinnitus, earache, and dysuria.(37) The studies only followed patients for 4 days post-vaccination. The most commonly used HepB vaccine contains thimerosal, although a relatively new release does not contain thimerosal. The vaccine also contains: aluminum hydroxide, yeast protein, and phosphate buffers.(38)
VARICELLA (CHICKENPOX): I have been informed of the risk of my child developing chicken pox which could potentially result in pneumonia, secondary skin or generalized infections, or, if caught during pregnancy, birth defects in the baby. I understand chicken pox is generally benign in children, but results in significant lost hours at work for parents. Chicken pox in adults often manifests as shingles, a chronic and painful condition. I also understand that contracting chicken pox later in life may increase my risk for herpes simplex. Side effects and adverse reactions for the chicken pox vaccine include: contracting chicken pox from the live vaccine (27%), pain and redness at site, swelling, erythema, rash, pruritus, hematoma, induration, stiffness, upper respiratory illness, cough, irritability/nervousness, fatigue, disturbed sleep, diarrhea, loss of appetite, vomiting, otitis, diaper rash/contact rash, nausea, eye complaints, chills, lymphadenopathy, myalgia, lower respiratory illness, headache, teething, malaise, abdominal pain, other rash, allergic reactions including rash and hives, stiff neck, heat rash/prickly heat, arthralgia, eczema/dry skin/dermatitis, constipation, itching, pneunonitis, febrile seizures, and cold/canker sore.(39) Varicella vaccine is cultured on cells from aborted babies, and guinea pig cell cultures. It contains live virus, monisodium glutamate (msg), sucrose, phosphate, processed gelatin, neomycin and fetal calf serum. (40)
HEPATITIS A (HAV): I have been informed of the risk of my child developing HAV which could potentially result in prolonged or relapsed hepatitis, but will not result in chronic hepatitis disease. (41) HAV usually causes mild "flu-like" illness, jaundice, severe stomach pains and diarrhea; and, in rare cases may result in death. Infection confers lifelong immunity. (42) I understand that the CDC admits that good personal hygiene (handwashing) and proper santitation can prevent HAV. (43) HAV infection is spread by contaminated water or food, infected food handlers, unsanitary conditions following natural disasters, ingestion of raw or undercooked shellfish, institutionalized individuals, children not yet toilet trained, blood
transfusions or sharing needles with infected people. Transmission is most likely in developing countries where sanitation is poor and infection rate of children under 5 is 90%. Fatality rate is less than .6% overall, and 70% of those in patients over 49 years, many of whom have underlying liver disease. (44) Other at-risk populations include those living on American Indian reservations and in Alaskan Native villages, homosexually active men, IV drug users, people using clotting factor concentrates and international travelers. (45) Side effects and adverse reactions from the vaccine include: injection-site soreness, headache, fever, malaise, induration, redness, swelling, fatigue, anorexia, nausea, pruritis, rash, utricaria, pharyngitis, upper respiratory tract infections, abdominal pain, diarrhea, dysgeusia, vomiting, arthralgia, elevated cratine phosphokinase, myalgia, lymphadenopathy, hypertonic episodes, insomnia, photophobia, and vertigo. (46) Aborted fetal tissue is an ingredient in the Havrix® Hep A vaccine, as is formaldehyde, aluminum hydroxide and 2-phenozyethanol.(47) There is currently a combination Hep A and B vaccine, Twinrix®, being tested in the UK. (48) Twinrix is grown in human cell cultures, contains 2-phenoxyethanol,
neomycin sulfate, polysorbate, tromentamol and formaldehyde. (49)
PNEUMOCOCCAL: I have been informed of the risk of my child developing pneumococcal disease which could result in meningitis, blood infection, pneumonia and/or ear infections. Iunderstand studies indicate that this vaccine may only decrease ear infections by 9%, and only result in a 20% reduction in chronic ear infections and ear tube insertion in that group. understand that my child has a 7.5:5,000 chance of developing this disease if he or she is under age 2 and a 1:5000 chance of developing it if over age 2. Risk factors for developing this disease are: immunoglobulin deficiency, nephrotic syndrome, Hodgkin's disease, congenital or acquired immunodeficiency, some upper respiratory infections, splenic dysfunctions, splenectomy or organ transplant. This vaccine (PCV) was originally marketed for immunocompromised children. (50) This vaccine is contraindicated to children with thrombocytopenia, coagualtion disorders, or sensitivity to diphtheria toxoid.(51) Possible side effects and complications from the vaccine include: erythema, induration, tenderness, interference of limb movement, inflamation, fever, irritability, drowsiness, restless sleep, decreased appetite, vomiting, diarrhea, fussiness, rash, hives, bronchitis, asthma, pneumonia, otitis media (ear infection), sepsis, seizure, anaphylaxis and death.(52) Recipients were followed for 3 days and almost 10% of the subjects made a visit to the emergency room in the follow-up period. There were 8 cases of SIDS in the 17,066 subjects involved in the trial.(53) Note: Children in the studies' control group received another experimental vaccine, so there have been no trial studies done with
children who received no vaccine.(54) Prevnar contains .125 mg of aluminum sulfate, protein polysaccharides from 7 strains of strep. pneumoniae bacteria, diphtheria toxin, casamino acids, yeast extract. Studies indicate that it may interfere with the safety and efficacy of other vaccines.(55)
1. M. Burnet and D. White, The Natural History of Infectious Disease
(Cambridge, 1972), p. 16.
2. Strebel, et al, "Epidemology in the U.S. One Decade After the Last
Reported Case of Indigenous Wild Virus Associated Disease," Clinical
Infectious Diseases, (Center for Disease Control, February 1992), pp.
3. Physician's Desk Reference (PDR), 50th Edition; Medical Economics, 1996,
4. Ibid, p. 885-886 and 891-892.
5. J. Butel, et al; "Molecular Evidence of Simian Virus 40 Infections in
Children", The Journal of Infectious Diseases ; September 1999;180:884-887.
6. PDR, 50th Edition, p. 872-875.
9. Richard Moskowitz, M.D., "Immunizations: The Other Side," Mothering,
10. Immunization: Survey of Recent Research, (United States Department of
Health and Human Services, April 1983), p. 76.
11. "Nature and Rates of Adverse Reactions Associated with DPT and DT
Immunizations...," Pediatrics, Volume 68, No. 5 (November 1981).
12. Walene James, Immunization the Reality Behind the Myth, (South Hadley,
Massachusetts: Bergin & Garvey, 1988), p. 14.
13. W.C. Torch, "Diptheria-pertussis-tetanus (DPT) immunization: A
cause of sudden infant death syndrome (SIDS)," (Amer. Academy of Neurology,
34th Annual Meeting, Apr 25 - May 1, 1982), Neurology 32(4), pt. 2.
14. PDR, p. 875-879 and 892-895.
16. Robert Mendelsohn, M.D., How to Raise A Healthy Child...In Spite of
Doctor (Chicago: Contemporary Books, 1984), p.223.
17. Ibid. 244-246
18. Isaac Golden, Ph.D., Vaccination? A Review of Risks and Alternatives,
(Geelong, Victoria, Australia: Arum Healing Centre, 1991), p. 31
19. Richard Moskowitz, M.D., "Immunizations: The Other Side," Mothering,
20. Isaac Golden, Ph.D., Vaccination? A Review of Risks and Alternatives;
21. R. Mendoholson; How to Raise a Healthy Child; p. 217.
22. John Frank Jr., M.D., et al. "Measles Elimination - Final Impediments,"
20th Immunization Conference Proceedings, May 6-9, 1985, p. 21.
23. Infectious Diseases (January 1982), p. 21.
24. PDR, p. 1610-1611.
25. DR, p. 1687-1689.
26. Sara Solovitch, "Do vaccines spur autism in kids?", San Jose Mercury
27. PDR, p. 1687-89, 1610-1611.
28. Richard Moskowitz, M.D., "Immunizations: The Other Side," Mothering,
29. PDR, 1708-1709.
31. R. Mendoholson; How to Raise a Healthy Child; p. 218.
32. Dr. Beverley Allan, Australian Nurses Journal, (May 1978).
33. Hannah Allen, Don't Get Stuck: The Case Against Vaccinations...,
(Oldsmar, FL: Natural Hygiene Press, 1985), p. 144.
34. DR, p. 1697-1699.
35. Ibid and Attenuation Of RA 27/3 Rubella Virus in WI-38 Human Diploid
Cells; Amer J Dis Child vol 118 Aug 1969 and Studies of Immunization With
Living Rubella Virus ; Arch J Dis Child vol 110 Oct 1965.
36. John Hanchette, "Safety of controversial hepatitis B vaccine at center
of debate" Gannett News Service, 5/18/99.
37. PDR, p. 1744-1747, 2482-2484.
39. PDR, p. 1762-1765.
41. CDC Viral Hepatitis A - Fact Sheet, 9/29/00;
42. CDC Hepatitis A Vaccine Vaccine Information Statement; 8/25/98 43. CDC
Hepatitis A Facts, 11/16/00
44. Mosby's GenRX®, 10th Ed., Hepatitis A Vaccine (003158) as posted on
45. CDC Hepatitis A Vaccine Vaccine Information Statement; 8/25/98 and CDC
Hepatitis A Vaccine Vaccine Information Statement; 8/25/98
46. Mosby's GenRX@, Hepatitis A Vaccine
48. "Combined hepatitis A/B vaccine offers fast protection," Reuters
49. Vaccines and Their Ingredients, 6/24/99; www.909shot.com
50. Michael Horwin, MA; "Prevnar: A Critical Review of a New Childhood
51. Prevnar package insert, Wyeth Lederle, 2/17/00
53. Horwin; "Prevnar: A Critical Review"
54. Dr. Erdem Cantekin, Ph.D.; "Pneumocaoccal Vaccine and Otitis Media",
NVIC's 2nd Intl. Public Conference, 9/8/00.
55. Horwin; "Prevnar: A Critical Review"
Refusal to Vaccinate
Child’s Name: Child’s ID#....................................................................
My child’s health care provider, , has advised me that my child (named above)
should receive the following vaccines:
Hepatitis B vaccine
Diphtheria, Tetanus, acellular Pertussis (DTaP) vaccine
Diphtheria Tetanus (DT or dT) vaccine
Haemophilus influenzae type B (Hib) vaccine
Pneumococcal conjugate vaccine
Polio vaccine (IPV)
Measles, mumps, rubella (MMR) vaccine
Varicella (chickenpox) vaccine
Influenza (flu) vaccine
Hepatitis A vaccine
I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Sheet(s) explaining the vaccine(s) and the disease(s) they prevent. I have had the opportunity to discuss these with my child’s health care provider, who has answered all of my questions regarding the recommended vaccine(s). I understand the following:
The purpose of and the need for the recommended vaccine(s)
The risks and benefits of the recommended vaccine(s)
If my child does not receive the vaccine(s), the consequences may include:
- contracting the illness the vaccine should prevent
- transmitting the disease to others
- the need for my child to stay out of daycare or school during disease outbreaks
My health care provider, the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention have all strongly recommended that the vaccine(s) be given Nevertheless I have decided to decline the vaccine(s) recommended for my child, as indicated above, by checking the appropriate box under the column titled "declined."
I know that failure to follow the recommendations about vaccination may endanger the health or life of my child and others that my child might come in contact with. I know that I may re-address this issue with my health care provider at any time , and that I may change my mind and accept vaccination for my child anytime in the future. I acknowledge that I have read this document in its entirety and fully understand it.
Parent/Guardian Signature Date
HE0342 Copyright ©2002 9-80
Documenting Parental Refusal to Accept Vaccination
All parents and patients should be informed about the risks and benefits of preventive and therapeutic procedures, including vaccination. In the case of vaccination, federal law mandates this discussion.Despite the health care provider’s best efforts to explain its importance, some families may refuse one or more vaccinations for their children. The use of this or a similar form may in some instances induce a wavering parent to accept your recommendations because it emphasizes the importance you place on being appropriately immunized. In addition to concern for the health of their unimmunized patient, health care providers may be concerned about liability. The American Academy of Pediatrics’ Committee on Infectious Diseases states:
Documentation of [vaccine risk communication] in the patient’s record may help to reduce anypotential liability should a vaccine-preventable disease occur in the unimmunized patient. Health care providers may decide it is in their best interest to formally document a parent’s refusal to accept vaccination for a minor child. This form, which should not be considered a legal document without advice from a lawyer, may be used as a template for such documentation. Completion of a form, in and of itself, never substitutes for good risk communication nor would it provide absolute immunity from liability. After completion of this form re-discussion of these issues at another time may still be appropriate. Completion of this form also does not provide a family with exemption from state school or day care entry requirements. If you think it appropriate to use in your setting, this form may be used in those instances where parents refuse to have their child vaccinated with one or more vaccines. The form may be duplicated or changed to suit your and your patients' needs.
Section on Infectious Diseases
Input from Committee on Bioethics
Committee on Community Health Services
Committee on Infectious Diseases
Committee on Medical Liability
Committee on Practice and Ambulatory Medicine
Section on Administration and Practice Management
Section on Computers and Other Technologies
American Academy of Pediatrics. Informing Patients and Parents. In: Pickering LK, ed. 2000 Red Book: Report
of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, IL:American Academy of Pediatrics; 2000:
Dear Dr. ________,
We're delighted that our (new child will be receiving) (our child is receiving) your excellent care and have every confidence in your caring, knowledge and professional judgment. At the same time, given recent concerns about the safety of Thimerosal, a preservative used in many vaccines, we have made the decision that our child receive only vaccines that you can guarantee in writing do not contain Thimerosal.
Despite the 1999 FDA phase-out of Thimerosal, we are aware that it's still present in many vaccines being offered to children. We are therefore asking that you check by reading the package insert on each and every vaccine intended for our child to assure that Thimerosal is not in the contents.
We then ask that you fill in the following list informing us of the type, manufacturer, and lot number of each vaccine, scheduled for our child at (birth, or Insert child's age and date and time of upcoming appointment).
In addition, we request that you inform us whether or not each vaccine does or does not contain Thimerosal. We would like to ascertain this information prior to our appointment and are available for further discussion.
In the event, that you cannot provide a Thimerosal-free vaccine for any given vaccine on our child's schedule, we want you to know that we withhold informed consent. We do not agree to our child's receiving that vaccine, or any other vaccine containing Thimerosal. If you can refer us to a provider using a Thimerosal-free vaccine, we would be most grateful.
Apart from our need for absolute certainty on this question, we intend to keep working with you, and thank you so much for taking the time and trouble to assure our child's health and safety.