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