Olmsted on Autism: The Art of Chess
Raun Kaufman on Vaccine Decision: Parents Know Best

The Warranty of Vaccine Safety For Pediatricians

For a printable version, click HERE.

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
_____________________________________________________ _______________________________
_____________________________________________________ _______________________________
_____________________________________________________ _______________________________
_____________________________________________________ _______________________________
_____________________________________________________ _______________________________
_____________________________________________________ _______________________________
_____________________________________________________ _______________________________
_____________________________________________________ _______________________________

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®)
•         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 thimerosal 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% 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% 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.

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: ________________________



Leann Wurtzinger

I am looking for assistance for a family court case with my 4 year old son. It was agreed upon before my son's father and I split up not to Vaccinate any further. I even have a Vaccination record from before I moved out where it states at the top not to vaccinate our child. Now 3 years later after he is married he has tried to hide doctor appointments and set them up with his step son who is 6 months older and have his wife take our child and him not even attend. I'm fighting this in court and need any assistance to help win against the court forcing me to vaccinate our child. I can go into further detail if needed. [email protected] is where I can be reached. Thank you for any assistance that is offered for this.

Jack Tar

Under the section on fillers, you may also want to add DHMO to the list; it's a common 'carrier' substance used to transport the vaccine toxins. Have a look at the Material Safety Data Sheet for it; this stuff qualifies as HAZMAT.


I think it's significant that it's also known as hydric acid.


Stacy, I think you were reading the comment below mine. I know that several vaccines are cultured in cell lines derived from aborted fetal tissue. You're preaching to the choir.

My comment about SV-40 was aimed at Ali, who said that only anti-abortion people would care about vaccines being cultured in aborted fetal tissue. I wanted Ali to know that aborted fetal tissue could also be spreading other diseases, the way monkey kidney tissue spread SV-40 to people receiving the polio virus.


This document, written by Ken Andersen at his blog, makemeyounger, is somewhat irresponsible.

I get that it is, in essence, a piece of satire that is meant to provoke serious discussion of the real issues surrounding vaccines. But, written such as it is, people think this is a "real" document, when it is NOT.

BTW, re: the comment by "Theresa" above who seems to think that vaccines are NOT manufactured from aborted fetal tissue...well, I hate to break the truth to you:


This article is written by a Navy doc and documents the entire sordid history of it.


Hey, Ali, you don't have to be anti-abortion to be concerned about potential transmission of human diseases through vaccines cultured in cell lines from aborted fetuses. SV-40 (from monkey tissue) causes mesothelioma; what human diseases are we spreading through vaccines cultured in aborted fetal tissue?


" 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”)."

Where did this come from? This smells a lot like someone snuck in some anti-choice/anti-women's rights rhetoric. Up until reading this, I was very excited at this possible advocacy tool and excited to share it, especially with my parent-to-be friends. Now I'm offended and shocked that no one else caught this. Spreading misinformation is the job of the vaccine industry, and advocates would be wise to wisen up to propaganda and call it out when they see it.


I wonder how many physicians, CDC officials, Big Pharma vaccine manufacturers, etc. vaccinate their children according to the recommended vaccine schedule. If it's safe for us, is it safe for them and their children?


let's just say that a certain major city convention and shopping centre has been educated as to vaccine ingredients. I think tomorrow the same thing might happen at a few community centres and hockey rinks. He he...


I wished I had this during 48 months the 40 vaccines were given to our twin boys (one regressed around 34 months old, dx'd with ASD at 48 months old)

But I know if I had, our pediatrician would not have signed this. I still find it all frustrating that on the very day the dr admitted Cameron had autism, she proceeded to give our twins 8 more vaccines on this very same day -- when they COULD have been spread out FROM ages 4 TO 6 years old! Nooo she gave them ALL on that very day before we even had a chance to know what the heck Autism was. Now they don't need another until they are 11 years old. (yea like that's going to happen now!)

IMHO, I think this letter should be made into a MANDATED LAW. If they can mandate ALL these nasty cocktail mixed vaccines and shove them down our throats in such a short time whether we want them or not, then Dr's and even the messed up government who has a big part in all this, should be MANDATED to SIGN THIS LETTER.

Concerned Parent

All I can say is WOW. What pediatrician (or any doctor in his right mind) would sign this???

And to say that if they do not sign is evidence that you are right is totally bogus. Its like answering the question "Did you beat your wife today?" If you say NO, I did not, you imply that you have in the past.

There is enough spam in this world, please dont add to it.


I LOVE THIS!!!!!!!!!!!

I am going to share far and wide!

Shauna Layton

I too wish that I had this years ago. I agree with the earlier comment about creating a movement with this form. We should print these out and send one to everyone we know, tell them to make copies and keep the cycle going. This is the truth, this is what is in our vaccines. If a doctor gets upset or claims it is false information, this only strengthens our case. I truly believe this could be a wonderful thing!

Shauna Layton-Founder
Together In Autism
[email protected]


While this form would possibly ridiculed by mainstream physicians, you can bet that maybe a few would send it to AAP or AMA. It's about time that physicians realize that today's parents are very educated and informed about vaccine safety. All of the comments we heard about how to restore trust in the parents regarding vaccines at the federal committee meetings---this may be a start. Provide the parents with the tools they need to make educated decisions and before long the physicians will realize parents are not going to back down.


Oh, how I wish I had this at my son's 4 year check up after we told the ex-pedi that we weren't getting shots. She quickly shoo'ed us out the door and said she couldn't see us anymore....


I chuckled about this, too, at first. But as I began to read further, I wondered if this might just be the beginnings of a new tactical approach. Not that a traditional pediatrician or a university or school district would sign something like this, but if each shot were exposed as the Hep B is so beautifully here, perhaps the folly of uninformed adherence to CDC or AAP advice could be unmasked.

jill r

i was going to something like this when my old pedi swore up and down that vaccines were safe and my daughter would be fine. i wasn't convinced since i saw what they did to my son. i wanted her held liable if something happened to my daughter. well i ended up just finding a new pedi.


Forgot amino acids, genetically modified Saccharomyces cerevisiae (bread yeast), destrose, mannitol, yeast extract, lactose, lecithin, latex, soy peptides & peptones, neomycin, gentamycin, polymixin B & xanthan gum.

Might as well include the list of the things the package inserts specifically mention as contraindications to receiving a vaccine - these are pretty much all cell culture and solution ingredients that are common allergens.

...as if that isn't why so many people are allergic to them...

At any rate, not that a doc would sign the statement to begin with, but what the heck - include the things OTHER THAN chemical toxins that screw with the immune system when an allergy is present (or that can create one), too...

Kathy Blanco

Thanks for sharing this, printing it out for my daughters and their friends.
I agree on the comment with mycoplasma. 6% of the childhood vaccines, have them in it. When tested, Dr Garth Nicholsen found 58% of children with autism tested, had mycoplasma Fermantens in them and or other species (there are around twenty). If the child has that, I would suggest, also testing for lyme and tick borne diseases at www.igenex.com .


I f'g love this. Am printing off a bunch and will distribute.


I thoroughly intend to hand it over to any medical practitioner that brings up the subject (and they ALL do!).

Thank you for making my day!


Awesome! I might also consider adding a section about aluminum hydroxide being associated with motor neuron death and Gulf War Syndrome. And how it's in Gardasil (and HepB?). And how there are so many reports of motor degeneration after Gardasil. And how Hep B has caused MS.

Asthma mom

There is no mention of mycoplasma in the vaccine ingredients. My doctor told me that mycoplasma in ASD kids comes from the vaccines. I found this link here:


It further turns out that a ton of research has found asthma in kids and adults linked to chlamydia pneumoniae AND mycoplasma. So, it was the vaccines that gave my child his asthma.



Anybody out there with asthma kids, it would help to treat for chlamydia pneumoniae and mycoplasma. For sure the mycoplasma came from the vaccines, I am unsure about the chlamydia.


I think every pediatrician should be handed a copy of this ASAP.



In fact, I intend to undertake a mailing to pediatricians in my area this week (and will expand from there in the weeks to come). The grassroots pediatricians may hold the key here, by implication, since there is such a blatant, concerted effort to mislead them.

Josh Day

This is also good to carry with you during hospital visits. Think of it as insurance if someone/someones get nasty. A pocket lawyer, if you will. No professional would ever sign it -- I doubt anyone would even take it, even to chuck into the trash around the corner -- but it's proof you are an informed parents and renders any threats of "negligence" moot.

Look into the recording laws in your area too. In many states it's legal to record conversations when only one party consents to the recording -- that party being you. We always carry a handheld recorder which we'd turn on in the event of a threat or intimidation tactic.


Nice early morning chuckle trying to picture myself handing this over to our pediatrician:-)

Maria Lenarduzzi

Great! absolutely globally sharable!

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