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Would Your Pediatrician Sign The Warranty of Vaccine Safety?

5.7KViews Modified: Dec 19, 2025 · Published: Nov 5, 2018
By Jacqueline 3 Comments

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Ask Your ProVacc Ped To Sign The Physician’s Warranty of Vaccine Safety, doctor signing warranty paperwork
Photo by rawpixel on Unsplash

A pediatrician’s recent comment on a blog I read a few weeks back got me thinking about how parents could best deal with the tactics that pediatricians frequently use to pressure their patients to vaccinate.

There are several strategies I have heard about or experienced first hand:

• The Fear Tactic

• “You Need The Shots for School”

• The Condescending “I know Better Than You” Attitude With Degrees On the Wall

• Threat To Drop a Patient – Clear Discrimination For a Legitimate Religious Objection To Vaccinations

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Get your free copy of the Vital Vaccine Info E-Book

Formal training in vaccine safety is not routinely conducted in U.S. pediatric residency programs.

Doctors are trained in administering vaccines, not in how they are made. Most doctors blindly support the recommendations of the American Medical Association and the American Academy of Pediatrics.

Ask Your ProVacc Ped To Sign The Physician’s Warranty of Vaccine Safety, Parents talking with pediatrician or doctor
(Source)

Not All Are Condescending

Not all doctors are condescending. Let me state that very, very clearly upfront. I know there are wonderful doctors out there who listen carefully and patiently and respond with humanity to the concerns of their patients!

However, many pediatricians are extremely condescending, especially when a parent questions vaccines! Even as a seasoned RN with questions, I was intimidated to the point of leaving a practice. I had the “I am a doctor, and you are only a nurse” ploy used on me.

Sometimes, the most intelligent people turn out to be the most myopic.

One Way To Respond If You Are A Parent Feeling Pressured

This is a brilliant and appropriate way to counter or respond to these tactics that a parent can use and maybe also help educate the many pediatricians who still may know very little about the vaccines they routinely give.

Caveat

Note & Caution:  Presenting this form COULD get you dismissed from a practice with some pediatricians even if parents were friendly and not threatening in demeanor. By its very legal nature, it could be construed as a threat. If your child is relatively healthy, it isn’t a huge deal. I know there are parents who have been dismissed from practices because of not vaccinating, or alternate vaccine scheduling (delay and selective vaccines), so I think it would not be unreasonable to think a parent could be dismissed for asking a doctor to sign this form.

Recently, more families are crossing over to more of a “no thank you” mindset. Thankfully, many “family practice” doctors are great about parents making decisions for their own children, because the pressure isn’t so great on them from the powers-that-be.

Obviously, I encourage you to learn as much as you can, become your own researcher, use no-side-effect natural remedies (such as I keep in my natural medicine cabinet) and stay away from the doctor’s office (and hospital) as much as possible.

The Physician’s Warranty of Vaccine Safety was developed in the 1990s by Harvey Wysong in response to neurodevelopmentalist Kay Ness’s desire to support the parents in dealing with pushy and condescending pediatricians.

You can find the original form here on her website.

.DOC (MS Word) version for printing
.PDF (Adobe Acrobat) version for printing

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 vaccines I intend to administer to protect against them:

Risk Factor                          Vaccine         Mfr.             Ser. #       Batch #         Exp. Date

_____________________________________________________ _____________________________________________

_____________________________________________________ _____________________________________________

_____________________________________________________ _____________________________________________

_____________________________________________________ _____________________________________________

_____________________________________________________ _____________________________________________

_____________________________________________________ _____________________________________________

_____________________________________________________ _____________________________________________

_____________________________________________________ _____________________________________________

I am aware that vaccines typically contain many of the following fillers:

• aluminum phosphate

• ammonium sulfate

• amphotericin B

• animal tissues: pig or horse blood, rabbit brain

• dog kidney, monkey kidney

• chick embryo, chicken egg, duck egg

• calf (bovine) serum

• beta propiolactone

• fetal bovine serum

• formaldehyde

• formalin

• gelatin

• glycerol

• human diploid cells (from aborted human fetal tissue)

• hydrolyzed gelatin

• mercury thimerosal (thiomersal, Merthiolate®)

• monosodium glutamate (MSG)

• neomycin

• neomycin sulfate

• phenol red indicator

• phenoxyethanol

• potassium diphosphate

• potassium monophosphate

• polymyxin B

• polysorbate 20

• polysorbate 80

• porcine (pig) pancreatic hydrolysate of casein

• residual MRC5 proteins

• sorbitol

• squalene

• sucrose

• tri(n)butyl phosphate,

• VERO cells, a line of monkey kidney cells

• washed sheep red blood

and, hereby, give warranty 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 (SV40) and that SV40 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 SV40 or any other live viruses. (Alternately, I hereby warrant that said SV40 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 and incorporated herein by reference, – “Physician’s Basis 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 and incorporated herein by reference, – “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 and incorporated herein by reference, – “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 Exhibit D , attached hereto and incorporated herein by reference, – “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 E , attached hereto and incorporated herein by reference, “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 warranty statement in both my business and individual capacities and hereby waive any statutory, Common Law, Constitutional, UCC, international treaty, Armed Forces exemptions, and any other legal immunities from liability lawsuits in the instant case.

I issue this warranty 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 warranty this _______ day of ______________ A.D. ________

Witness: ___________________________________ Date: ________________________

Notary Public: ______________________________  Date: ________________________


.DOC (MS Word) version for printing
.PDF (Adobe Acrobat) version for printing

Parents, I want you to be informed and know your rights for your children’s health, protection and welfare. Find more here: Vaccine Exemption Information & Requirements For Each State

Vaccine E-Book
Get your free copy of the Vital Vaccine Info E-Book

More For Research

Strabismus, Facial & Spinal Asymmetry Occurring Post-Vacc: Look For It

What I’d Tell You Over Coffee If You Asked Why We Didn’t Vaccinate

Prompt Vaccine Detox Info If You Ever See Your Child or Baby Regress

Numerous Doctors Conclude We’re Not Told Truth About Vaccine Safety

Study: Vaccinated vs. Unvaccinated Children: Guess Who Is Healthier?

Neurotoxin Aluminum In Hepatitis B Vaccine – A Pediatrician’s Warning

Warning: If You Vaccinate Don’t Give Glutathione-Depleting Acetaminophen

Evidence: HPV Vaccine Caused This Woman’s Stage 3 Cancer

Gardasil Vaccine: Beware Of Blindly Following Doctor’s Schedule

22,000 US Nurses Refuse Flu Vaccines At Expense Of Career

Those trying to teach about vaccine dangers have only one motivation: to prevent more suffering. We have either witnessed it first hand in our own family or know those who have.

“Liberty, once lost, is lost forever.” ~John Adams, letter to Abigail Adams, Jul. 17, 1775

***For the Full Spike Protein Protocol to protect from transmission from the “V” and to help those who took the “V”, go here.

***If you found value in this writing, please share it, discuss it, and subscribe to my FREE newsletter. Independent, ad-free work like this spreads because of readers like you.

Also, please consider supporting my work by using my Amazon affiliate link when purchasing from there.

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Censorship is real, so my Pinterest account was suspended; thankfully, a big part of my main board is still alive through this link!

You can also find me on Facebook, Gab, MeWe, X (Twitter), and Instagram.

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Hi! I’m Jacqueline!

Thanks for being part of this journey with me.
Welcome to my own little place on the internet! Home is where I love to be. I feel there is no greater place to incubate souls. These days you’ll find me using my experiences here to write about herbal remedies and natural health research — a big passion of mine. But being a wife and mother is not easy. It is challenging and potentially lonely. I get that. I wanted to create a place to connect with and support other moms for creating a natural, healthy, and fulfilling home life.
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Reader Interactions

Comments

  1. sahmpaw

    June 05, 2018 at 7:20 pm

    This is brilliant! Thank you for sharing.

    Reply
  2. meg

    June 06, 2018 at 9:12 pm

    This is very interesting! My husband is in the medical field/first responder and has had to write a rather lengthy response in his refusal to take the flu vaccine…. I know that more vaccines will ultimately be forced on him if he isn’t ready to do something about it. I wonder if this could be used for that as well??

    Also, curious if anyone has used this and had good luck with it???? Anyone???

    Reply
  3. vex 3

    June 11, 2018 at 9:53 pm

    Thanks for sharing this useful information

    Reply

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