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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: __________