‘Acknowledament ond Guarantee, |, the undersigned physician, acknowledge and agree to the following on this date {1am a stato-icensed physician who administers vaccines in the usual course of my business and in accordance with the medical standard of care, The child patient before me i known to me in my ‘medical practice and has no conditions that qualify as contraindications to vaccination. It's my intention to vaccinate ths patient with one or more vaccines in the Centers far Disease Control and Prevention’s (COC) Recommended immunization Schedule for Persons Aged O Through 18 Years. | am familiar with the COCs Vaccine Excipiont & Media Summary. lam aware that the vaccine(s)| intend {t0-administer may contain the following: aluminum, which is a known neurotoxin that may be aco- {actor in developing Alzheimer's disease; polysorbate 80, which may cause adverse reproductive effects: formaldehyde, which sa known carcinogen; phenoexyethanol, wbich is known to be toxic to the renal, digestive and nervous systems; Triton X-100, which is known to cause adverse developmental and reproductive effects; a thimerosal, which s S0% ethylmercury and which has serious neuretoxic effects ‘when compounded by environmental exposure to methylmercury, | am knowledgeable in the dangers of uiltraslow dose exposure of endocrine-disrupting chemicals to developing bodies. {1am aware thatthe National Childhood Vaccine Injury Act of 1986, while acknowledging that vaccine {juries and deaths ate a reality, reduced the financial liability of vaccine administrators and ‘manutacturers for vaccine injury claims. am also aware of the United States Supreme Court 2012 ‘ruling in Breusewitz v. Wyeth which barred vaccine injured plaintiffs from suing vaccine manufacturers, but did not offer vaccine administrators the same protection. | acknowledge that while my professional labilty for vaccine injury i limited by the National Childhood Vaccine Injury Act of 1986, itis not removed entirely. Despite the absence of clinical double blind studies for vaccine safety, thave advised my patient/patient’s caregiver of the extreme rarity of occurrence of ‘moderate to severe vaccine injury. Therefore, in the interest of fairness and justice and in full consideration for payment for the vaccines | am providing through my practice, [am waiving ll protections afforded to me under the National Childhood Vaccine Injury Act of 1985. {unconditionally and irrevocably, assume personal financial responsibilty for this patient for allfuture health conditions not currently manifested that develop within 180 days after each occurrence where | rect my staff to administer vaccines to the patient, These conditions include, but are not limited to, ‘Type 1 diabetes, asthma, food allergies, eczema, Attention Deficit Disorder/Attention Defieit and Hyperactivity Disorder, Obsessive Compulsive Olsorder, Anxiety Disorders, Sensory Processing Disorder, Sudden infant Death Syndrome, epilepsy, encephalitis, Autism Spoctrum Disorder, ovarian failure, Guillain-Barre syndrome, as well as all cancers. Within 30 days | will fuly pay each invoice submitted to ‘my office on this patient's behalf, including but not limited to invoices for in-office medical care, hospital stays, prescriptions, therapeutic services, and funeral costs. Physician Signature: tient Name: Physician SSN Patient $8N