Indemnity Form. Copy and Print: Invite healthcare professionals who wish to use a syringe to inject into you what they call the Covid-19 Vaccine to complete and sign it. Translate this form to your language and share with your friends and family.

One for the Dr or nurse wanting to jab you
Conditional Acceptance Vaccine Safety Clause and Professional Declaration
Complete and sign this Acceptance and clause before the vaccine shall be administered.
1. I am the Soul / Guardian / Carer of the Beneficiary and NHS patient, granted and assigned with full powers of attorney, over the biological estate of calling / name ___________________________________ / Born Day /D.O.B_____/________/________
2. I am the patient……. calling / name__________________________________
3. Born Day / D.O.B_____/________/________
Today’s Date: ___ / ___ / ___
Full Name position and title of nurse/administrator/medical professional_______________________
Hospital/Practice CEO name and office___________________________________________
please delete as applicable.
As a medical practitioner, I am held by The Hippocratic oath. Yes / No – please delete as applicable.
“The first point of the Hippocratic is to do no harm. And I will use treatments for the benefit
of the ill in accordance with my ability and my judgment, but from what is to their harm and
injustice I will keep them.”
Please tick the answer Yes, or No to the following questions:
I the administer of the vaccine have read the list of ingredients Yes | No
I have studied all of the ingredients in the vaccine and can say they are safe to administer: Yes | No
I understand all of the ingredients in the vaccine and the possible side effects: Yes | No
I understand the vaccine contains MRC-5 aborted foetal cells, or any other form of DNA. Yes | No
I understand there is a possibility of an Iatrogenic Reaction (adverse reaction from multiple compounds or drugs interacting with each other) from the vaccine Yes | No
I hereby can also prove I have qualifications in chemistry and have studied chemistry to the level of understanding the chemical reactions that will occur as a result of the combination of ingredients within the vaccine Yes | No
I the vaccine giver will not only be held professionally and personally responsible for any resulting medical complications as a result of this vaccine. Yes | No
If the answer is No to any of the above, then we agree that due to the Hippocratic oath and
my duty of care, which is to the patient, that I grant the patient the right to decline the
vaccine today
In the case of (Patient’s name) ______________ Age _____
Signed __________________________
Practice _______________________
Witnessed by in the presence of:
Calling / Name ____________________________________
Date______/_______/2021
Telephone number not essential optional:_______________________
Email address:____________________________________________
Witnessed by in the presence of:
Calling / Name ____________________________________
Date______/_______/2021
Telephone number not essential optional:_______________________
Email address:____________________________________________