Home » Say NO to Vaccines Community » Doctor’s LONG form to verify vaccine safety

Doctor’s LONG form to verify vaccine safety

I came across this form to help people challenge their doctor (pediatrician) on the safety issues concerning all vaccines.  What is GREAT about these forms is that it gets things stirring; i.e. questions rolling that can not be answered without implicating the entire vaccine-fraud cartel.  What is bad about these forms is that no doctor in the right mind, that you may well want your children to frequent, will ever sign it; after reading the first few sentences it is likely to wind up in the trash and you will be asked to leave and take your kids with you elsewhere.  Here is the form, then we’ll talk more about better options afterwards;

Physician’s Warranty of Vaccine Safety

I (Physician’s name, degree)_________________________, _____
am a physician licensed to practice medicine in the State of
________________. My State 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 ___________________________________________

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 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:_________________

Phewwwwwwwwwwwwwww!  As if anyone is ever going to take this seriously!  HA!

Now this “elsewhere” to go I spoke of before, is usually the issue, nes’t pas?  Where to go when you want your kids to visit a good pediatrician when most are brainwashed into the vaccination-fraud dogma?

There are plenty of reputable MD’s who will sign off on your kids vaccines knowing full well they place their license on the line by doing so; I did it here in Hawaii for years.  You just have to take some time to get into the community “in-the-know.”  There’s probably one closer than you think, since many MD’s remember their altruistic purpose for being a doctor in the first place; to help and serve people as a human being with knowledge.  Not tout bureaucratic-for-profit vaccine fraud policies that have done nothing but made children less healthy.

In Dr. William Trebing’s fabulous book, Good-Bye Germ Theory, he notes easier ways to convince an MD you actually like to sign off on your kids vaccines.  You need to remember that although they fully understand that present day pharma-trash vaccines are no good, they still do not want to loose their practice and livelihood.  So work it out with them in private, and have them sign something more palatable like this waiver to liability from page 267 of Dr. Trebing’s book;

Your name, address and date here

Going to:

CERTIFIED MAIL #

Affidavit

Release from Liability of Disease

Dear ( doctor, school official or government employee):

I, , hereby release you in all ways, legal and

otherwise, from any liability or blame that may occur if I, or my

child becomes ill to any extent with a disease as a result of not

receiving the State of mandated vaccinations.

I as a parent (or individual) of sound mind and body release and

totally indemnify you from any claim, fault, liability or blame

which may occur as a result of my decision to not vaccinate myself

or my child for any particular disease, whether or not such vaccines

are mandated by State law. I assume full responsibility for any

consequences, legal or otherwise, that follows as a result of my

decision to not vaccinate myself, or ____________ (child’s name).

Signed this day of , (year)

Printed name

Signature

268

STATE OF )

)ss

COUNTY OF )

BEFORE ME, the undersigned authority, ,

known to me (or satisfactorily proven) to be the persons whose

names are subscribed to the foregoing instrument, personally

appeared and acknowledged to me that they executed the same as

their free act and deed for the purposes and considerations herein

expressed and the capacity stated, ant that the statements contained

herein are true and correct to the best of their information,

knowledge, and belief.

Subscribed and sworn to before me this day of , 20___ .

IN WITNESS WHEREOF, I have set my hand and official seal:

Notary Public

County,

My commission Expires:

NOTARY SEAL:

 

Hi its me, Dr. Tyler again…………..  Now I feel an approach like this makes more sense.  Doctors are not the problem folks; and if you believe they are then you need to completely study this issue.  One way to do this is to listen to my upcoming Web-Radio show, Health Care Freedom and The Dr. Tyler Durton Hour. First show TBA.

The thing I love about Dr. Trebing’s book is that he gives you paperwork answers that are not so adversarial and thus, actually have the ability to accomplish something.  For example, its a good idea to simply have your sympathetic MD give you a “Medical Exemption” which most states have within their vaccine laws.  You are aware of the cumbersome “Religious Exemption,” which works but takes some doing.  A “Medical Exemption” is a free pass that all will accept.  Why is the doctor giving your child a medical exemption under that law?  That’s private, between you and your MD and no one can ask you to divulge that info, especially some school nurse lackey with an over developed sense of importance.  Here is the paperwork from Good-Bye Germ Theory;

269

Your name, address and date here

Going to:

CERTIFIED MAIL #

Memorandum in Law

Request for Medical Exemption Under State Statute

Dear Doctor :

Our particular State provides under the law a category for medical

exemption to it’s mandated vaccination policy. This exemption

needs to come from a doctor of medicine, and therefore I am

requesting such an exemption for due to the

following set of medical facts.

No vaccine can be deemed totally safe, since warnings of many

symptoms and disorders arising from a vaccine can be found

within the packet inserts of all vaccines the State requires by

mandate. could very possibly be effected adversely

from these vaccines by the manufacturer’s own admission,

therefore should receive a medical exemption.

The State of has not presented me with any personal

guarantee, written or otherwise, that myself or my child will NOT

be harmed by said vaccines the State has mandated.

You have not presented me with any personal guarantee, written

or otherwise, that myself or my child will NOT be harmed by said

270 DR. WILLIAM P. TREBING

vaccines the State has mandated. Therefore I can safely assume

that you believe some harm or risk is possible for ,

and therefore a medical exemption is warranted.

The following school officials in order (list them all), who are

blocking entrance of my child to school until such vaccines are

administered, have not presented me with any personal guarantee,

written or otherwise, that my child will NOT be harmed by said

vaccines the State has mandated. This medical exemption is

necessary so that can return to school.

A listing of valid research, stating that the vaccinations mandated

by the State of are linked to disorders such as autism,

mental retardation, ADHD, decreased intelligence, cancer,

disorders of the skin, allergies, disorders of the eyes and ears, sudden

infant death syndrome, Parkinson’s disease, dementia, Alzheimer’s

disease, respiratory and cardiac failure, chronic nervous system

dysfunction, meningitis, encephalopathy, seizures, anemia, and

epilepsy to name but a few, is included with this Request for Medial

Exemption Under State Statute. Since no one can guarantee me

that will not receive any of these conditions

as a result of being vaccinated, a medical exemption is necessary

and legally indicated.

The said vaccinations mandated by the State of do

not guarantee that myself or my child will not acquire the diseases

in which they claim to prevent, therefore a medical exemption is

necessary.

There is no state of emergency regarding any of the diseases the

State of is attempting to control with the vaccinations

mandated.

Since the majority of the population of the State of is

vaccinated by their own choice for themselves and their children,

if it is truly the position of the State that the vaccinations mandated

GOOD-BYE GERM THEORY 271

do control the spread of the diseases they are given for, then my

choice not to vaccinate myself or my child cannot possibly create

any harm to the vaccinated population.

Since the majority of the population of the State of is

vaccinated by their own choice for themselves and their children,

if it is truly the position of the State that the vaccinations mandated

do control the spread of the diseases they are given for, then my

choice not to vaccinate myself or my child cannot possibly create

an epidemic of any kind that poses a risk to the other citizens of

the State.

The State of cannot adequately prove that I am placing

myself, or my child in danger of acquiring a disease by my choice

to not vaccinate, since to date there have been few scientific studies

on the general health of unvaccinated persons, vs. the general health

of vaccinated ones, within any given population. Private research

groups have studied the general health of select unvaccinated people,

and the results are that unvaccinated people are generally healthier

than the vaccinated population.

I am of sound mind and body, and reserve all my common law

rights to non-invasion of my body, or my child’s body, to chemicals

being injected into us that we do not approve of, or agree with.

I am of sound mind and body, and reserve all my common law

rights to make all the decisions regarding the direction of my life,

and the direction of the life (lives) of my child (children), especially

with regard to their safety, emotional and physical well-being.

I reserve all my rights under the uniform commercial code, particularly

UCC 1-201, UCC 1-207 and UCC 3-501, and hereby rescind any

and all contracts I may have signed with the State of ,

which caused me to unknowingly waive any of my common law rights,

or rights granted to me under the constitution of the united states

of America, particularly my first amendment right to religious

272 DR. WILLIAM P. TREBING

freedom, and my ninth and tenth amendment rights to have my

other” rights not denied or disparaged, and protected under the

common law.

I am of sound mind and body, and it is my firm philosophical

belief that the said vaccinations mandated by the State

of , have been proven by science to be extremely harmful

to my body, or my child’s body. Under this belief, and the belief

that said mandated vaccinations will create harm to myself or my

child, I hereby refuse such vaccines to be entered into my body or

the body of my child without my permission and against my will.

As such harm can very possibly occur to , a

medical exemption is necessary.

I reserve all my legal rights to privacy granted to me under the Bill

of Rights, the ninth and fourteenth amendments of the constitution

of the united states of America. This right to privacy includes my

right to control my own body, and the body of my child, and to

make fundamental decisions about my life or the life of my child.

Vaccines are harmful to the body, and by their very nature are an

assault on the body. There is always a risk of dangerous side effects

following the administration of the State of _______ mandated

vaccines, as is noted by the manufacturer of said vaccines. I further

declare that my right, and my child’s right to privacy is

fundamental at the common law, especially when the State cannot

prove that my decision to not vaccinate myself or my child will in

any way harm anyone, or create a potential risk to anyone.

Therefore, a medical exemption is necessary for ______________.

Sincerely,

273

STATE OF )

)ss

COUNTY OF )

BEFORE ME, the undersigned authority, ,

known to me (or satisfactorily proven) to be the persons whose

names are subscribed to the foregoing instrument, personally

appeared and acknowledged to me that they executed the same as

their free act and deed for the purposes and considerations herein

expressed and the capacity stated, ant that the statements contained

herein are true and correct to the best of their information,

knowledge, and belief.

Subscribed and sworn to before me this day of , 19 .

IN WITNESS WHEREOF, I have set my hand and official seal:

Notary Public

County,

My commission Expires:

NOTARY SEAL:

274

Doctors area

I, Dr. , licensed to practice medicine in the

State of , hereby grant a medical exemption

for to not receive vaccinations for the reasons

stated in this legal notice. Due to this, the medical exemption

clause of our State’s vaccination law applies to ,

and he/she should not receive these vaccinations mandated by the

State.

Doctor’s printed name

Doctor’s signature

Witness

Witness

Note: to make this easier on your doctor, have him/her sign this

portion in their office, and then ask for a signed confirmation of

this medical exemption on the doctor’s letterhead as well.

Otherwise, the doctor may have to accompany you to a notary,

which is unlikely. You can also have your doctor’s staff cut and

paste this section on their letterhead, which will save even more

time.

Dr. Tyler again……………………

Okay so I  believe this is a much smarter approach then running around screaming with belligerent forms.  Give it a try and let me know if you have any questions; an hey, why not just buy the book on Amazon?  A $22 investment you’ll be glad you own.

Peace, Ty

 

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