________ day of ________________, ________
____________________ (the vaccinator) of ________________________________________________________(address) and ____________________________ (patient) of ________________________________________________________(address) .
Despite many claims, Vaccines are neither safe nor effective to everyone. Even the manufacturers believe there is a risk to some people.
For that reason, I will never know whether or not the vaccine will be safe or effective to myself, so to ensure that I am looked after should anything untoward happen to me after receiving the vaccine, can you please fill out the form below.
I ____________________ (the vaccinator) the undersigned, hereby agree that the vaccination _________________________ (name of vaccine), I am about to administer to ____________________________ (the patient) is both safe and effective and carries no harmful effects of any kind.
As long term effects from _________________________ (name of vaccine) any vaccine remain an unknown entitiy, should ____________________________ (the patient) fall sick or die within 6 months of receiving the _________________________ (name of vaccine) vaccine, from any sickness or condition, I will be personally responsible for their complete health care as well as paying compensation of £500,000 from my own personal finances.
I believe it so strongly I am willing to put this money into escrow right now, so should ____________________________ (the patient) fall sick or die it will be there for them or their families to use as they see fit, no questions.
If after 6 months of having the vaccine, there are no side effects of any kind, the money will be returned to me.
Name in Capitals __________________________