Doctor’s/Physician’s

Warranty of Vaccine Safety

I (doctor’s name, degree)__________________________________________, am a

physician/medical doctor licensed to practice medicine in Queensland.
My registration 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 fully 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 and adjuvants:
· aluminium hydroxide
· aluminium phosphate
· ammonium sulphate
· amphotericin B
· animal tissues: pigs blood, horse blood, rabbits brain, broth of cows 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 foetal tissue)
· hydrolized gelatin
· mercury (thimerosal/thiomersol)
· monosodium glutamate (MSG)
· neomycin
· neomycin sulphate
· phenol red indicator
· phenoxyethanol (anti-freeze)
· potassium diphosphate
· potassium monophosphate
· polymyxin B
· polysorbate 20
· polysorbate 80
· porcine (pig) pancreatic hydrolysate of casein
· residual MRC5 proteins
· sorbitol

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· sucrose
· 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. Reports to the contrary, such as reports that mercury in
thimerosal/thiomersal may cause 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 virus or other viruses pose no risk
whatsoever 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 "foetuses").

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 and extensively investigated the causes for adverse vaccine reaction and I'm
certain that the vaccines I am recommending are completely safe for administration to a child
under the age of 5 years.

I am aware that …………………………………………. (patient name) is a conscientious objector in

the matter of vaccinations and has not given valid consent1 as required by dot point 2, of section
1.3.3 [page 12] of The Australian Immunisation Handbook 9th Edition.

I also warrant that the mandated and forced vaccination/s by Queensland Health Department for
…………………………………………(patient name), will not cause …………………………………..
(patient name) any adverse reactions as listed in either section 1.5.2 2 [Adverse events following
immunisation] and Appendix 63 [Definitions of adverse events following immunisation] of The Australian
Immunisation Handbook 9th Edition.

The following double blind, placebo, controlled studies have been performed to demonstrate the
safety of vaccines in children under the age of 5 years.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

In Case of Hep B Vaccine.

"Physician’s reasons for determining the invalidity of adverse scientific opinions."
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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 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.

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/doctor’s Warranty of Vaccine Safety in my professional capacity as

the attending physician/doctor, 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, personal 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/lawyer/barrister, admitted to the Bar in
the State of _________________________

_________________________________ (Name of attending physician/ doctor)

__________________________________ under my full commercial liability. (Signature of

attending physician/doctor)

Signed on this ________________ day of ______________ A.D. _________

Witness Signature: ______________________________ Date:____________

Witness name:_________________________________ (Please print full name)

Notary Public: ______________________________ Date: ___________

solicitor/barrister:

Note:
Any information herein is for educational purpose only, it may be news related, purely
speculation or someone's opinion.
None of the above should be construed to be legal or medical advice.
Always consult with a trusted, qualified health and legal practitioner before deciding on
any course of action or treatment, especially for serious or life-threatening illnesses.
Please always do your own research to ensure the truth or otherwise of the above
statements.
Excerpts from The Australian Immunisation Handbook 9th Edition -
1
1.3.3 Valid consent
Valid consent can be defined as the voluntary agreement by an individual to a proposed procedure, given after appropriate and reliable information
about the procedure, including the potential risks and benefits, has been conveyed to the individual. 3-7
For consent to be legally valid, the following elements must be present:8
• It must be given by a person with legal capacity, and of sufficient intellectual capacity to understand the implications of being vaccinated.

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• It must be given voluntarily.
• It can only be given after the relevant vaccine(s) and their potential risks and benefits have been explained to the individual.
• The individual must have sufficient opportunity to seek further details or explanations about the vaccine(s) and/or their administration.
Consent should be obtained before each vaccination, once it has been established that there are no medical conditions that contraindicate vaccination.

2
1.5.2 Adverse events following immunisation
3
Appendix 6: Definitions of adverse events following immunisation

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