COVID 19 VACCINATION

INDEMNITY NULLIFICATION STATEMENT!

TO BE SIGNED ONLY BY THE INDIVIDUAL WHO IS ADMINISTERING THE VACCINATION!

I, being the person administering the Covid 19 vaccination, know, declare and swear that the injection and
or medication that I will be giving today will in no way and at any time cause any harm to the patient. I do
accept information here given that I am not obligated to follow orders from any individual to administer any
medication or vaccination which can cause injury, illness, serious illness or death. The onus is on myself
to not do so and I take full responsibility for my actions.

If I am wholly not sure or wholly not aware of the complete and proper composition or effects of this
medical treatment I am being told to administer and if I proceed with this medical treatment, then I deem it
is of my own personal free will and I will be culpable and accept full responsibility for any adverse effects.

I accept the law of the land and international common law and denounce the damnable doctrine that harm
may be authorized or given indemnity by authority of acts of parliament.

I understand and wholly accept that if my own actions are causing any harm, serious harm or death then I
may be declared an International outlaw whereby no Government legislative or other organization
whatsoever can give me lawful indemnity or protection and as an enemy of humanity (Hosti Humanu Gen-
eris) my life may be at risk as a due and lawful punishment should I continue to administer a vaccination
or other medication.

I hereby state that it is without any threat to me to do so, and entirely of my own mind to act and accept
responsibility of my actions. Therefore I willingly sing my name below and accept that I have read and un-
derstood the words of this statement.

Sign here with wet ink

Print your name

Date of medical vaccination

Name of patient

Hospital or clinic or other place attended

THIS FORM TO BE RETAINED BY THE PATIENT.