Guest guest Posted November 11, 2001 Report Share Posted November 11, 2001 - " mm0121 Mail Account " <mm0121 " Helene Austin " <maxmc2121; " 1Luann " <Luanns; " 1Betsy " <betsyczinger Wednesday, March 14, 2001 7:29 PM Fw: Great " Vaccine Refusal Form " > > - > " Ingri Cassel " <vaclib > <Undisclosed-Recipient:@cobalt.avistacom.net;> > Wednesday, March 14, 2001 2:17 PM > Great " Vaccine Refusal Form " > > > > Dear Members and Friends - > > I am getting alot more requests for how to obtain exemptions to vaccines > > and how to deal with militant doctors. Attached is a WordDocument, > > " The Vaccine Peace of Mind " form for doctors to fill out and below is > > another one to be used to let your doctor know that you are also very > > informed and clearly more so than they are! Good luck! Ingri > > ***************************************************** > > > > This form was originally put together by a Ped. who wanted to scare her > > clients into vaccinating their children. I have included her original > > (with corrected typos - PLEASE, you'd think she would have checked it > > first!) and my updated form. The purpose of this form is to give clients > > both sides of the side effect story, which they obviously didn't get > > with hers! This is NOT an exemption form, but a form to help provide > > informed consent or INFORMED REFUSAL. It's LONG!!!!!!! Please feel free > > to disseminate as WIDELY as possible. > > _____________ > > > > Vaccine Refusal Form > > > > http://www.pcc.com/lists/pedtalk.archive/9708/0439.html > > For those of you who requested a copy of the immunization refusal form > > we use, here it is: > > > > Linda L. Shaw MD, FAAP--Pediatrics > > Mercy Health Services > > 2613 8th Ave., Suite 2E > > Altoona, PA 16602 > > phone: 814-941-4377 > > > > REFUSAL OF RECOMMENDED VACCINES > > > > Patient Name_______________________________Birthdate_______________ > > > > As the parent(s)/guardian(s) of _____________________________, I/we have > > discussed with Dr. Shaw the risks and benefits of the following > > initialed vaccines: > > > > POLIO: I/we have been informed of the risk of my child(ren) developing > > paralytic disease and meningitis associated with poliomyelitis. > > Initial_____________Date________ > > > > HEMOPHILUS INFLUENZAE B: I/we have been informed of the risk of my > > child(ren) developing meningitis, pneumonia, and infections of the > > blood, joints, bone, and soft tissue associated with Hemophilus > > Influenzae B. > > Initial______________Date_______ > > > > PERTUSSIS: I/we have been informed of the risk of my child(ren) > > developing whooping cough, pneumonia, convulsions, inflammation of the > > brain, and death associated with pertussis. > > Initial______________Date________ > > > > DIPTHERIA: I/we have been informed of the risk of my child(ren) > > developing paralysis, heart failure, or respiratory failure associated > > with diphtheria. > > Initial_______________Date________ > > > > TETANUS (LOCKJAW): I/we have been informed of the risk of my child(ren) > > developing fatal neuromuscular disease related to tetanus. > > Initial________________Date________ > > > > RUBEOLA (MEASLES): I/we have been informed of the risk of my child(ren) > > developing pneumonia, encephalitis (inflammation of the brain), > > degenerative disease of the nervous system with convulsions (subacute > > sclerosing panencephalitis) related to rubeola. > > Initial_________________Date________ > > > > MUMPS: I/we have been informed of the risk of my child(ren) developing > > inflammation of the testicles, joints, kidneys, and/or thyroid, and > > hearing impairment related to mumps. > > Initial_________________Date________ > > > > RUBELLA (GERMAN MEASLES): I/we have been informed of the risk of my > > child(ren) developing inflammation of the brain or joints, and of the > > risk of birth defects (including eye defects, heart defects, deafness, > > mental retardation, growth failure, jaundice, and disorders of blood > > clotting) in infants born to mothers who contract rubella during > > pregnancy, related to rubella. > > Initial_________________Date________ > > > > HEPATITIS B: I/we have been informed of the risk of my child(ren) > > developing Hepatitis B viral infection which can cause chronic > > inflammation of the liver leading to cirrhosis, liver cancer, and > > possibly death. > > Initial_________________Date________ > > > > VARICELLA (CHICKENPOX): I/we have been informed of the risk of my > > child(ren) developing varicella viral infection which could potentially > > result in pneumonia, secondary skin or generalized infections, or, if > > caught during pregnancy, birth defects in the fetus. > > Initial_________________Date________ > > > > I/we understand that by refusing the vaccines initialed above, I am > > acting against the recommendations of my child(ren)'s physician(s) and > > am placing my child(ren) at risk for developing the conditions described > > above. I/we understand that Linda L. Shaw MD and/or Mercy Health > > Services or any of its employees or physicians are not legally liable > > for any claims or expenses that may arise should any of my child(ren) > > contract one or more of the above illnesses. By signing this statement, > > I/we acknowledge that I/we are aware that the above illnesses can safely > > be prevented by commonly administered immunizations and that I/we are, > > of our own free will and with full disclosure, acting against the > > recommendations of Linda L. Shaw MD and/or employees of Mercy Health > > Services and refusing the above initialed immunizations for our > > child(ren). I/we acknowledge that I/we have received written and verbal > > information about each of the conditions listed above and have had ample > > opportunity to have my/our questions answered by our child(ren)'s > > physician. > > > > Signature (mother)_______________________________Date____________ > > > > Signature (father)________________________________Date____________ > > > > Signature (guardian)______________________________Date____________ > > > > Signature (Physician/PA/NP)_______________________Date____________ > > > > Signature (Witness)_______________________________Date____________ > > > > The above consent form is placed in the chart & a copy given to the > > parent(s). The parent(s) are also given immunization information sheets > > and, if they desire, information about each of the illnesses copied from > > the RED BOOK of infectious disease. The parents are informed that they > > may change their mind(s) about immunization at any time and that our > > office will be glad to immunize their child(ren). > > > > Hope this helps! > > > > Linda Shaw MD > > ------------------------------- > > NEW and Updated Form with my changes > > ****************************** > > INFORMED REFUSAL OF RECOMMENDED VACCINES > > > > Patient Name_______________________________ Birthdate_______________ > > > > > > As the parent/guardian of __________________________, I have > > investigated the risks and benefits of the following vaccines and > > diseases. I am aware that there are documented cases of people > > contracting diseases for which they are clinically fully immunized and > > that the manufacturers of the vaccines do not guarantee 100% efficacy. I > > am also aware that VAERS (Vaccine Adverse Events Reporting System) > > documented cases of over 54,000 adverse reactions from vaccines in a > > 20-month period. The National Vaccine Injury Fund, created in 1986 to > > compensate those damaged by vaccines has paid out over one billion > > dollars in compensation to date. > > > > POLIO: I have been informed of the risk of my child developing paralytic > > disease and meningitis associated with poliomyelitis. I understand that > > even under epidemic conditions, natural polio produces no symptoms in > > over 90% of those exposed to it.(1) I understand that there have been no > > cases of wild polio in the US in the last 20 years and that those cases > > which have been documented have been caused by the vaccine.(2) > > I understand the following side effects for the vaccine are possible: > > Killed virus polio: temperature of 102° in up to 38%, sleepiness, > > fussiness, crying, decreased appetite, vomiting, Guillain-Barré Syndrome > > and allergic reaction in those allergic to neomycin, polymyxin B and > > streptomycin. Precautions include those who have had a previous negative > > reaction, pregnant women, and possibly those with HIV/AIDS or otherwise > > compromised immune systems. Live virus polio: Reactions include > > contraction of polio by those who have received the virus and by those > > who have come into contact with body fluids and wastes of the immunized > > person. Paralytic symptoms may follow contraction of polio. Live virus > > is reportedly shed for up to 8 weeks after the inoculation. > > Guillain-Barré Syndrome has also been noted. Not recommended for use in > > households where someone has a compromised immune system, for pregnant > > women, or where a previous reaction has been reported.(3) > > Killed polio virus vaccine is grown on monkey kidney cells, contains > > formaldehyde, and triple antibiotics. Poliovax is grown on cells from an > > aborted baby, contains formaldehyde, cow serum and triple antibiotic > > solution.(4) The monkey kidney cells used in the original killed polio > > vaccine contains SV-40 virus and has been found in tumor cells of > > children whose parent's were vaccinated against polio using the > > contaminated virus.(5) The live vaccine is grown on monkey kidney > > cells, antibiotics and calf serum. > > Initial_____________Date________ > > > > HEMOPHILUS INFLUENZAE B: I have been informed of the risk of my child > > developing meningitis (although this vaccine will not protect the child > > from meningitis from all other forms such as pneumococcus, and > > meningococcus, viruses, and fungi), pneumonia, and infections of the > > blood, joints, bone, and soft tissue associated with Hemophilus > > Influenzae B. I understand that this disease is most likely in children > > up to 15 months of age and is fatal in 3-6% of children who contract it. > > Incidence of this disease today is low and the vaccine has not proven to > > be highly effective in 41% of cases, according to some studies.(6) > > Treatment is available. The vaccine is often combined with the DPT which > > has the highest reaction rate of any vaccine available today. Reactions > > include: contracting HIB, localized pain, erythema and induration, fever > > up to 100.6°, irritability, lethargy, anorexia, rhinorrhea, diarrhea, > > vomiting, cough, when administered alone. Reactions occurred in up to > > 30% of patients. When administered in conjunction with the DPT, > > reactions include local tenderness erythema and induration, fever up to > > 100.8°, irritability, drowsiness, anorexia, diarrhea, vomiting, > > persistent crying, seizures, urticaria, hives, renal failure, > > Guillain-Barré Syndrome and death. Reactions occurred in up to 77.9% of > > patients.(7) The vaccine contains yeast, thimerosal (mercury > > derivative), and diphtheria toxoid when given alone.(8) > > Initial______________Date_______ > > > > PERTUSSIS: I have been informed of the risk of my child developing > > whooping cough, pneumonia, convulsions, inflammation of the brain, and > > death associated with pertussis. I understand the disease is rarely > > fatal, with a 99.8% recovery rate. It is most serious and > > life-threatening in children under 6 months old, but there are adequate > > methods of treatment available.(9) The vaccine is most often given in > > conjunction with diphtheria and tetanus as the DPT or as the DaPT. > > Pertussis vaccine may cause: fevers 106 degrees, pain swelling, > > diarrhea, projectile vomiting, excessive sleepiness, high--pitched > > screaming, inconsolable crying bouts, seizures, convulsions, collapse, > > shock, breathing problems, brain damage and SIDS. One in 600 suffer a > > severe reaction in one study (10) and 1 in 875 suffered shock-collapse > > and convulsions.(11) Those in the 2nd study were only tracked for the > > first 48 hours following immunization. A more recent study indicates > > that 1 in 100 react with convulsions, collapse, or high-pitched > > screaming and 1 in 3 of those cases sustained permanent brain > > damage.(12) In a study of 103 children who died of SIDS, 70% died within > > 3 weeks of the DPT vaccine and 37% of those died within the first > > week.(13) The DaPT is recommended as a safer option for vaccination. > > Side effects of the DaPT were only tracked for 72 hours and included: > > tenderness, erythema, induration, fever up to 102.2°, drowsiness, > > fretfulness, vomiting, upper respiratory infection, diarrhea, rash, > > febrile seizures, persistent or unusual crying, lethargy, > > hypronic-hyporesponsive episode, urticaria, anaphylactic shock, > > convulsions, encephalopathy, mono- and polyneuropathies and death.(14) > > Not recommended for children under 15 months or for those who have not > > had 3 injections of the DPT. Either form of the vaccine contains > > thimerosal (mercury derivative), formaldehyde, and aluminum > > phosphate.(15) > > Initial______________Date________ > > > > DIPHTHERIA: I have been informed of the risk of my child developing > > paralysis, heart failure, or respiratory failure associated with > > diphtheria. I have also been informed that there have only been 5 cases > > reported annually since 1980.(16) I am also aware that diphtheria is > > rarely fatal and treated with antibiotics and bed rest. (17) > > The Diphtheria component is most often given within the DPT or DaPT and > > includes the same side effects and reactions as those listed for > > pertussis. > > Initial_______________Date________ > > > > TETANUS: I have been informed of the risk of my child developing fatal > > neuromuscular disease related to tetanus. I understand that the > > incidence of tetanus is low, and there is an antitoxin, should we > > decline the immunization. I understand that contracting tetanus does not > > provide life-long immunity, and neither does the vaccine. I understand > > that to prevent more severe reactions from the vaccine, the tetanus > > component has been so significantly " diluted " that it is clinically > > ineffective.(18) I understand that the death rate for properly treated > > cases of tetanus may be as high as 20%.(19) > > Side effects of the tetanus vaccine alone include: high fever, pain, > > recurrent abscess formation, inner ear nerve damage, demyelinating > > neuropathy, anaphylactic shock and loss of consciousness.(20) > > Tetanus given in the DPT or DaPT shot include the same side effects and > > reactions as those listed for pertussis. > > Initial________________Date________ > > > > RUBEOLA (MEASLES): I have been informed of the risk of my child > > developing pneumonia, encephalitis (inflammation of the brain), > > degenerative disease of the nervous system with convulsions (subacute > > sclerosing panencephalitis) related to rubeola. I understand the death > > rate for measles is .03 in 100,000.(21) I understand that since 1984, > > over 55% of documented, confirmed cases of measles have been in fully > > immunized persons.(22) I understand that the greatest risk of the > > measles vaccine may be to push the incidence of this disease into the > > late teens and adulthood where it is more likely to be fatal or cause > > more adverse and long-term effects.(23) The measles vaccine is a live > > vaccine, and carries the risk that it will cause the patient to contract > > measles. Other adverse reactions include: stinging or burning at the > > injection site, anaphylaxis, fever up to one month following injection, > > rash, cough, rhinitis, erythema multiforme, lymphadenopathy, urticaria, > > diarrhea, febrile convulsions, seizures, thrombocytopenia, purpura, > > vasculitis, optic neuritis, retrobulbar neuritis, papillitis, retinitis, > > encephalitis and encephalopathy, ocular palsies, Guillain-Barré > > Syndrome, ataxia, and subacute sclerosing panencephalitis.(24) > > Measles vaccine is most often given as a part of the MMR which includes > > the following side effects: burning or stinging at injection site, > > malaise, sore throat, cough, rhinitis, headache, dizziness, fever, rash, > > nausea, vomiting, diarrhea, erythema, induration, tenderness, > > lymphadenopathy, parotitius, orchitis, nerve deafness, thrombocytopenia, > > purpura, allergic reactions, urticaria, polyneuritis, arthralgia, > > arthritis, anaphylaxis, vasculitis, otitis media, conjunctivitis, > > febrile convulsions, seizures, syncope, erythema multiforme, optic > > neuritis, retrobulbar neuritis, papillitis, retinitis, encephalitis and > > encephalopathy, ocular palsies, Guillain-Barré Syndrome, ataxia, > > subacute sclerosing panencephalitis,(25) and a recent study from Europe > > indicates that there may be a link between the MMR > > (measles/mumps/rubella) vaccine and autism and irritable bowel > > syndrome.(26) Measles vaccine contains chick embryo cells, neomycin, > > sorbitol and hydrolyzed gelatin. MMR contains all live vaccines, chick > > embryo, cells from aborted babies, neomycin, sorbitol and hydrolyzed > > gelatin.(27) > > Initial_________________Date________ > > > > MUMPS: I have been informed of the risk of my child developing > > inflammation of the testicles, joints, kidneys, and/or thyroid, and > > hearing impairment related to mumps. I understand that mumps is rarely > > harmful in childhood, and that most of the above risks occur when mumps > > is contracted in adolescence or adulthood.(28) > > I understand that there is a Mumps vaccine which poses the following > > risks: contraction of mumps from the live vaccine, burning or stinging > > at the injection site, anaphylaxis, cough, rhinitis, fever, diarrhea, > > vasculitis, parotitis, orchitis, purpura, urticaria, erythema > > multiforme, optic neuritis, retrobulbar neuritis, syncope, encephalitis, > > febrile seizures, and nerve deafness.(29) > > Mumps is usually given in the MMR and may cause those side effects and > > adverse reactions as noted in the measles section above. Mumps vaccine > > is live and should not be given to pregnant women. It is cultured in > > chick embryos and contains sorbitol and hydrolyzed gelatin.(30) > > Initial_________________Date________ > > > > RUBELLA (GERMAN MEASLES): I have been informed of the risk of my child > > developing inflammation of the brain or joints, and of the risk of birth > > defects (including eye defects, heart defects, deafness, mental > > retardation, growth failure, jaundice, and disorders of blood clotting) > > in infants born to mothers who contract rubella during pregnancy, > > related to rubella. Therefore, I understand that the greatest risk to my > > child may be if she never contracts rubella as a child, but when she is > > pregnant and it damages her unborn child. If she contract rubella in > > childhood, she is immune for life, and prior to the vaccine 85% of the > > population was immune.(31) I understand that if she is not immune as an > > adult, she can choose to take the vaccine prior to becoming pregnant. I > > understand that many of those who contract rubella have been immunized > > (up to 80%). (32) > > Adverse reactions among teenage girls is 5-10% and 30% in adult > > women.(33) Adverse reactions include: contracting rubella from the live > > virus in the vaccine, burning or stinging at the site, lymphadenopathy, > > urticaria, rash, malaise, sore throat, fever, headache, dizziness, > > nausea, vomiting, diarrhea, polyneuritis, arthralgia, arthritis, local > > pain and inflammation, erythema multiforme, cough, rhinitis, vasculitis, > > anaphylaxis, syncope, optic neuritis, retrobulbar neuritis, papillitis, > > Guillain-Barré Syndrome, encephalitis, thrombocytopenia, purpura, and > > Chronic Fatigue Syndrome. (34) > > Rubella is most often administered in the MMR and may cause those side > > effects and adverse reactions listed under measles. > > Rubella is cultured on the tissue of an aborted child; the 27th child > > aborted and tested due to exposure by his mother when she was pregnant. > > It contains neomycin, sorbitol and hydrolyzed gelatin.(35) > > Initial_________________Date________ > > > > HEPATITIS B: I have been informed of the risk of my child developing > > Hepatitis B viral infection which can cause chronic inflammation of the > > liver leading to cirrhosis, liver cancer, and possibly death. I > > understand that my child's risk of developing Hepatitis B is low if I am > > not a carrier or infected, if my child does not engage in promiscuous > > sex or use drugs. I understand that there is antibiotic treatment for > > HepB and that most of those who contract it recover.(36) I understand > > that the HepB vaccine only contains strains of HepB and is not effective > > against HepA, C, D, E, F, or G. I understand that the HepB vaccine has > > the following side effect and adverse reactions: induration, erythema, > > swelling, fever, headache, dizziness, pain, prutitus, ecchymosis, > > sweating, malaise, chills, weakness, flushing, tingling, hypotension, > > flu-like symptoms, upper respiratory illness, nausea, anorexia, > > abdominal pain and cramping, vomiting, constipation, diarrhea, > > lymphadenopathy, pain or stiffness in muscles and joints, arthralgia, > > myalgia, back pain, rash, urticaria, petechiae, sleepiness, insomnia, > > irritability, agitation, anaphylaxis, angioedema, arthritis, > > tachycardia/palpitations, bronchospasm, abnormal liver function tests, > > dyspepsia, migraine, syncope, paresis neuropathy, hypothesis, > > paresthesis, Guillain-Barré Syndrome, Bell's Palsy, transverse myelitis, > > optic neuritis, multiple sclerosis, thrombocytopenia, eczema, purpura, > > herpes zoster, erythema modosum, alopecia, conjunctivitis, keratisis, > > visual disturbances, vertigo, tinnitus, earache, and dysuria.(37) The > > studies only followed patients for 4 days post-vaccination. The most > > commonly used HepB vaccine contains thimerosal, although a relatively > > new release does not contain thimerosal and is limitted for use in > > newborns. The vaccine also contains: aluminum hydroxide, yeast protein, > > and phosphate buffers.(38) > > Initial_________________Date________ > > > > VARICELLA (CHICKENPOX): I have been informed of the risk of my child > > developing chicken pox which could potentially result in pneumonia, > > secondary skin or generalized infections, or, if caught during > > pregnancy, birth defects in the baby. I understand chicken pox is > > generally benign in children, but results in significant lost hours at > > work for parents. Chicken pox in adults often manifests as shingles, a > > chronic and painful condition. I also understand that contracting > > chicken pox later in life may increase my risk for herpes simplex. Side > > effects and adverse reactions for the chicken pox vaccine include: > > contracting chicken pox from the live vaccine (27%), pain and redness at > > site, swelling, erythema, rash, pruritus, hematoma, induration, > > stiffness, upper respiratory illness, cough, irritability/nervousness, > > fatigue, disturbed sleep, diarrhea, loss of appetite, vomiting, otitis, > > diaper rash/contact rash, nausea, eye complaints, chills, > > lymphadenopathy, myalgia, lower respiratory illness, headache, teething, > > malaise, abdominal pain, other rash, allergic reactions including rash > > and hives, stiff neck, heat rash/prickly hear, arthralgia, > > eczema/dry skin/dermatitis, constipation, itching, pneunonitis, febrile > > seizures, and cold/canker sore.(39) > > Varicella vaccine is cultured on cells from aborted babies, and guinea > > pig cell cultures. It contains live virus, glutamate, sucrose, > > phosphate, processed gelatin, neomycin and fetal calf serum. (40) > > Initial_________________Date________ > > > > Reference List > > > > 1. M. Burnet and D. White, The Natural History of Infectious Disease > > (Cambridge, 1972), p. 16. > > 2. Strebel, et al, " Epidemology in the U.S. One Decade After the Last > > Reported Case of Indigenous Wild Virus Associated Disease, " Clinical > > Infectious Diseases, (Center for Disease Control, February 1992), pp. > > 568-79. > > 3. Physician's Desk Reference (PDR), 50th Edition; Medical Economics, > > 1996, > > p. 1388-1390. > > 4. Ibid, p. 885-8860and 891-892. > > 5. J. Butel, et al; " Molecular Evidence of Simian Virus 40 Infections in > > Children " , The Journal of Infectious Diseases ; September > > 1999;180:884-887. > > 6. PDR, 50th Edition, p. 872-875. > > 7. Ibid. > > 8. Ibid. > > 9. Richard Moskowitz, M.D., " Immunizations: The Other Side, " Mothering, > > (Spring1984),p. 34. > > 10. Immunization: Survey of Recent Research, (United States Department > > of > > Health and Human Services, April 1983), p. 76. > > 11. " Nature and Rates of Adverse Reactions Associated with DPT and DT > > Immunizations..., " Pediatrics, Volume 68, No. 5 (November 1981). > > 12. Walene James, Immunization the Reality Behind the Myth, (South > > Hadley, Massachusetts: Bergin & Garvey, 1988), p. 14. > > 13. W.C. Torch, " Diptheria-pertussis-tetanus (DPT) immunization: A > > potential cause of sudden infant death syndrome (SIDS), " (Amer. Academy > > of Neurology, 34th Annual Meeting, Apr 25 - May 1, 1982), Neurology > > 32(4), pt.2. > > 14. PDR, p. 875-879 and 892-895. > > 15. Ibid. > > 16. Robert Mendelsohn, M.D., How to Raise A Healthy Child...In Spite of > > your Doctor (Chicago: Contemporary Books, 1984), p.223. > > 17. Ibid. 244-246 > > 18. Isaac Golden, Ph.D., Vaccination? A Review of Risks and > > Alternatives,(Geelong, Victoria, Australia: Arum Healing Centre, 1991), > > p. 31 > > 19. Richard Moskowitz, M.D., " Immunizations: The Other Side, " Mothering, > > (Spring1984), p. 34. > > 20. Isaac Golden, Ph.D., Vaccination? A Review of Risks and > > Alternatives; p. 71 > > 21. R. Mendoholson; How to Raise a Healthy Child; p. 217. > > 22. John Frank Jr., M.D., et al. " Measles Elimination - Final > > Impediments, " > > 20th Immunization Conference Proceedings, May 6-9, 1985, p. 21. > > 23. Infectious Diseases (January 1982), p. 21. > > 24. PDR, p. 1610-1611. > > 25. PDR, p. 1687-1689. > > 26. Sara Solovitch, " Do vaccines spur autism in kids? " , San Jose Mercury > > News, 5/25/99. > > 27. PDR, p. 1687-89, 1610-1611. > > 28. Richard Moskowitz, M.D., " Immunizations: The Other Side, " Mothering, > > (Spring1984),p. 35. > > 29. PDR, 1708-1709. > > 30. Ibid. > > 31. R. Mendoholson; How to Raise a Healthy Child; p. 218. > > 32. Dr. Beverley Allan, Australian Nurses Journal, (May 1978). > > 33. Hannah Allen, Don't Get Stuck: The Case Against Vaccinations..., > > (Oldsmar, FL: Natural Hygiene Press, 1985), p. 144. > > 34. PDR, p. 1697-1699. > > 35. Ibid and Attenuation Of RA 27/3 Rubella Virus in WI-38 Human Diploid > > Cells; Amer J Dis Child vol 118 Aug 1969 and Studies of Immunization > > With Living Rubella Virus ; Arch J Dis Child vol 110 Oct 1965. > > 36. John Hanchette, " Safety of controversial hepatitis B vaccine at > > center of debate " Gannett News Service, 5/18/99. > > 37. PDR, p. 1744-1747, 2482-2484. > > 38. Ibid. > > 39. PDR, p. 1762-1765. > > 40. Ibid. > > ************************ > > > > Rev. Kathy Rateliff; Certified Christian Doula, Certified > > Christian Childbirth educator, Christian Doula & Childbirth > > Educator Trainer, Student Midwife > > Author, Titus 2 Birthing Curriculums: Titus 2:1-8 > > NEW AND IMPROVED - See our website updated 9/15/99! > > http://www.geocities.com/titus2birthing/ > > <Rateliff <Titus2 > > > > > > > > ============================== > > Ingri Cassel, President > > Vaccination Liberation - Idaho Chapter > > P.O. Box 1444 > > Coeur d'Alene, Idaho 83816 > > (208)255-2307/ 765-8421 > > vaclib > > > > " The Right to Know, The Freedom to Abstain " > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 11, 2001 Report Share Posted November 11, 2001 I say to that doctor that she should sign a form saying she is personally responsible if any damage to the child DOES result from the vaccine. I have heard of parents asking doctors to do just that.... And I would ask her to drink the vaccine cocktail that's been offered (there a huge cash reward to any doctor who will actually take it). If this doctor/office is so pigheaded about the issue, let them put their money and responsible where their forms are! Femme Elaine121 wrote: > ....snip...... ***************************************************** > > > > > > This form was originally put together by a Ped. who wanted to scare her > > > clients into vaccinating their children. I have included her original > > > (with corrected typos - PLEASE, you'd think she would have checked it > > > first!) and my updated form. The purpose of this form is to give clients > > > both sides of the side effect story, which they obviously didn't get > > > with hers! This is NOT an exemption form, but a form to help provide > > > informed consent or INFORMED REFUSAL. It's LONG!!!!!!! Please feel free > > > to disseminate as WIDELY as possible. > > > _____________ > > > > > > Vaccine Refusal Form > > > > > > http://www.pcc.com/lists/pedtalk.archive/9708/0439.html > > > For those of you who requested a copy of the immunization refusal form > > > we use, here it is: > > > > > > Linda L. Shaw MD, FAAP--Pediatrics > > > Mercy Health Services > > > 2613 8th Ave., Suite 2E > > > Altoona, PA 16602 > > > phone: 814-941-4377 > > >...........snip..........n Quote Link to comment Share on other sites More sharing options...
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