Baby Immunisation Consent Forms


Physician’s Warranty of Vaccine Safety Form

The following form was adapted from Ken Anderson’s original. Perhaps you can find a physician that will sign it because I have no record of that ever happening:


Physician’s Warranty of Vaccine Safety

I (Physician’s name, degree)_________________________, _____ am a physician licensed to
practice medicine in the State/Province of ________________, in the country of
_________________. My State/Province license number is _______________ , and (if the USA)
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 ___________________________________________
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
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 thimerosol 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
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/Province of __________________.
__________________________________ (Name of Attending Physician)
__________________________________ L.S. (Signature of Attending Physician)
Signed on this _______ day of ______________ A.D. ________
Witness: _______________________________ Date: _____________________
Notary Public: ___________________________Date: ______________________



SA Vaccination refusal school letter Nov 2012

I/We, ________________________________________________ the parents / guardians
of _____________________________________ hereby state that we have chosen to not
vaccinate our child due to medical (and/or) religious/conscience concerns.
We maintain that we have investigated the reported risks and benefits of vaccination. We
maintain we are making a responsible and ethical choice for the following reasons:
1. Vaccination is a medical intervention performed on a healthy child that has the ability
to injure or cause the death of the child;
2. The fact that there cannot be a guarantee that the deliberate introduction of live or
killed microorganisms into the body of a healthy child will not compromise the health
or cause the death of that child, either immediately or in the future;
3. there are no predictors in science that can give advance warning that injury or death
may occur in any particular child that is vaccinated;
4. there are no proven assurances that the vaccine will protect the child from contracting
the disease;
5. there is an absence of adequate scientific knowledge regarding the way vaccines
interact with the human body on a molecular level.
Therefore, we believe that vaccination is a medical procedure that could reasonably be
termed as experimental each time it is administered to a healthy child.
We accept full responsibility for the health of our child.
In the event any of “vaccine-preventable” disease outbreak in our community, our child is
the one at risk, our child will remain home. We understand your facility would exclude our
child and we will gladly make arrangements for our child stay home.
We are aware that Paragraph 16 of the NATIONAL EDUCATION POLICY ACT, 1996
that on application for admission, a parent must show proof that the learner has been
immunised against the following communicable diseases: polio, measles, tuberculosis,
diphtheria, tetanus and hepatitis B. We are aware that paragraph 16 states that if a parent
is unable to show proof of immunisation, the principal must advise the parent on having
the learner immunised as part of the free primary health care programme. We understand
that although we must be advised on immunising this is not a condition for admission. We
also acknowledge the advisement on vaccinating for the polio, measles, tuberculosis,
diphtheria, tetanus and hepatitis B and confirm respectfully that we decline all vaccinations
for our child.
We are also aware that section 9 (3) and (4) under the Bill of Rights on Equality states:
neither “the State” nor “any person” may “unfairly discriminate, directly or indirectly, against
anyone on one or more grounds” including “religion”, “conscience” and “belief”. We are
aware that ISASA (Independent Schools Association of Southern Africa) adheres to South
Africa’s Constitution and Bill of Rights
Signed on this ___ day of ________________ 201__ at _______________________
Signed by: (name) _________________________(signature)____________________
Signed by: (name) _________________________(signature)____________________

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