Physician Accountability Form for Review and Signature Before Vaccinations



Physician Accountability Form for Review and Signature Before Vaccinations

Accountability form for doctor’s to read and sign for vaccines


I, the undersigned, being a qualified health professional, having assumed decision-making power independently, or having been appointed to such, by a government bureaucracy or health corporation controlled by such, do request or require the following named individual:

_________________________________________  to receive the following Vaccination(s), __ [for which I can now supply the certified Test Results for the Vaccine’s safety & efficacy: 


contrary to laws of this state that provide religious, philosophical & health-based exemptions.

II further agree that the stated individual(s) listed hereon are in excellent to perfect health, or have health concerns/issues prior to the administration of such immunization(s).

Consistent with this requirement / request and my Hippocratic Oath to do no harm is my personal acceptance of full responsibility for any and all damages resulting from such immunizations.   As a result, I agree to provide compensation amounting to $1,000,000.00 to the family/ies of the persons I am requiring to receive the aforementioned vaccinations for each resulting vaccine related injury(s), side-effect(s) and/or disease(s) as follows:

Sudden infant death syndrome:
Shaken baby syndrome:
Cerebral bleeding:
Auto-immune disease(s):
Bowel blockage:
Brain damage:
Mental retardation:
Crippling arthritis:
Mercury poisoning:
Loss of IQ:    
Chronic fatigue syndrome:

Other known – specify ______________________________________________________

*Note that virtually all of the above conditions /diseases are incurable by modern medicine, but more easily prevented by abstinence!

Name (print):_____________________ Position:_______________ at __________________.

Signature:_______________________Phone______________Date:______________ 201__

When you receive your passport, it might be wise to request a copy of
Foreign Rules and Regulations, Part 71, Title 42, on immunizations.  The World Health Organization (W.H.O.) in Geneva grants American visitors the right to refuse vaccinations when traveling internationally. 

                                CAVEAT:  Remember the basic rule:

  No one may vaccinate against an individual’s will unless, by so doing, the enforcer assumes full responsibility for consequences, both legal and medical.

When traveling abroad, you may secure exemptions from vaccines by using Clause 83 of the International Sanitary Code, issued by the W.H.O. (World Health Organization) and adopted by all its members. It states, in effect, that only when coming from an infected area are vaccinations necessary or the traveler could be quarantined for up to 14 days from the time he left the infected area if the health department deems it necessary.                   If you come from an area where there has been an epidemic, you will probably be put under surveillance (close watch). This simply means that together with the local health officer you must keep a close watch for any suspicious signs or symptoms. You will probably be required to report periodically to your local health officer for a period of up to 14 days from the time of departure from the infected area. If you notice an outbreak or symptom, you must immediately turn yourself in and submit to quarantine or isolation.

In actual practice, not only is this possibility very remote, but if it should occur, the un-vaccinated person may be required to submit to the same surveillance as the vaccinated! Remember, every year, many thousands of ‘unimmunized’ tourists travel in and out of the United States with little or no inconvenience or embarrassment.

It is quite obvious that no individual in his right mind will sign this document.                       The intention is not to get an individual to accept responsibility in this way, but to:                                 

Realize that there is a considerable risk.  Realize that they themselves could care less that someone else is injured.  Realize that they will accept no responsibility for vaccine related injuries.                            

Become acquainted with the risks and to accept responsibility by not forcing compliance to some bogus rule, standard or guideline that is not the law at all.   It is intended to put the official on the defensive that is a substantially weakened posture.   Further, it is a response to the intimidation that is often encountered.   If an individual refuses to sign on, ask the following question:   “Why not?   Am I supposed to accept all of the responsibility and my child to accept all of the health risks from your/doctor’s order?”

Then offer to negotiate the potential settlement, and ask:  

“How does one establish the monetary value of suffering?”

“Is it worth nothing to you?”

“What is the law and what does it state?”

“How does this present any risk to others ? – especially, IF vaccines work?”

“Who (all) benefits financially from this (mass) vaccination program?”

Answer:   The school district gets federal money if there is 100% compliance.

[He or she should start to get the message.]

Submitted by _________________________________ Phone# ____________________

Address ______________________________________  Email _____________________


Click here to download the “Physician Accountability Form””