Vaccination Notice of Non-consent for Physicians and Schools


Before submitting a vaccination notice to the physician, request the package insert for the vaccine he/she wishes to give you or your child. Do not accept CDC vaccine information sheets as a substitute. Do not decide while in his/her office, but take it home and read it.


(5) the doctor or nurse offers you. It is imperative that you present your own notice to them instead. The following notice is written from the point of view of a well informed rational parent, because most certainly the benefits of today’s vaccines do not outweigh the risks. The Vaccination Notice

(6) is designed to inform the doctor, hospital or school of the reasons you are opposed to their administering vaccines to your child and that you will only consent if they agree to accept the liability – in writing, which they would never do. The statements listed on the notice are factual and easy to validate. This approach should help put an end to the endless arguments that pediatricians and others inflict on vaccine-aware parents.


1. Items in grey need to be personalized.

2. Select son or daughter as applicable.

3. Corporate entities need to be in all caps.

4. The health department of each state is listed in its corporate name in all caps on Dun and Bradstreet. That information is accessible for free online.

5. At the bottom of the notice is a space for the parent’s signature and the signature of two witnesses.

Of course the dates need to be identical. An acceptable alternative to two witnesses would be to sign in front of a notary and have them stamp it for you. Use blue ink for signatures.


This notice requires little discussion. Just hand it to the nurse or doctor. Politely explain that you are not comfortable with the vaccine risks and wish to have this notice placed in the child’s records so you don’t have to bring in a new one each time your child sees the doctor or nurse. If asked where you obtained the document, simply say from another parent, which is true. Giving more information is neither required nor advisable. Citing websites or vaccine-aware organizations just motivates those in the vaccination-distribution-business to track down and discredit folks that are doing their best to bring good information to the public. And, frankly where you get your information is none of their business.

Do not answer detailed questions about your objections to any vaccine. Just repeat what is on the notice; “I am aware of multiple scientific peer-reviewed papers that have exposed the dangers of many vaccines.”

Doctors and nurses are well armed with ‘talking points’ designed to overcome all claims you might make regarding vaccines and nearly all authors you might site. According to Russell Blaylock, MD there are lots of peer-reviewed articles on this topic for doctors and nurses to read. It is their job to seek this information. It is not your job to provide it to them. The notice just states facts and is designed to be self-explanatory. Should the clerk, doctor, or nurse refuse to accept your notice, remind them that legal notices are an important element in due process.

Keep a copy for yourself and put the name of the employee who accepted (or rejected) the notice and the date it was delivered on the bottom of the page. Should school employees refuse to place the notice in your son or daughter’s file, refer them to the “Notice to agent is notice to principal clause”.

Write Notice refused by Agent (first and last name) on such and such date in the space at the top of the notice. Then take the notice home and send it certified mail (with return receipt) to the Superintendent of the school. Include a short explanatory letter. Following is a sample letter for the school superintendent.

(5) For more information go to; “DO NOT SIGN”

(6) See Notice


SAMPLE IV – single page notice –


Notice to agent is notice to principal – Notice to principal is notice to agent

As the living flesh and blood mother of Sally Doe Sally Doe (whose address is 2525 Maple Lane, Grove City, Ohio (no zip)), I am prohibited by law from endangering my son or daughter; therefore, I declare the following:

1) I am aware that those ordering and/or administering vaccines have been granted immunity from liability should my son or daughter suffer from a vaccine caused injury or illness. Since the Supreme Court decision Bruesewitz v. Wyeth (Feb 22, 2011), drug companies are under no legal obligation to insure their vaccine products are either safe or effective. The same decision defined vaccines as unavoidably unsafe. The Vaccine Injury Compensation Trust Fund is not an acceptable alternative to me. (Reason listed below – #10)

2) Unless I receive the vaccine manufacturer’s package inserts, I have not been given full disclosure regarding any vaccine. CDC or public health vaccine information sheets and/or websites are not acceptable alternatives. (Reasons listed below – #4 & #5)

3) I am aware that vaccine schedules have been established by the CDC and are promoted by public health departments, the American Academy of Pediatrics and other organizations. I do not accept CDC recommendations as science-based. (Reasons listed below – #4 & #6)

4) I do not recognize the CDC as a government health advocacy organization. It is a corporation listed on Dun and Bradstreet and headquartered in the STATE OF GEORGIA, with strong ties to the pharmaceutical industry. Therefore, their recommendations are influenced by the ‘fiscal’ health of their corporation.

Dun and Bradstreet Corporate Listing

5) I am aware that physician records are reviewed by the HEALTH, OHIO DEPARTMENT OF, a corporation headquartered in COLUMBUS OH and listed on Dun and Bradstreet, and who receive monetary compensation from the CDC to perform this function. Therefore, the state public health department’s recommendations and actions are influenced by the ‘fiscal’ health of their corporation.

6) I do not recognize the AMERICAN ACADEMY OF PEDIATRICS nor the AMERICAN ACADEMY OF FAMILY PHYSICIANS as health advocacy organizations. They are both corporations (listed on Dun and Bradstreet) that are headquartered in the STATE OF ILLINOIS and the STATE OF KANSAS respectively, whose monetary compensation from the vaccine manufacturers contributes to the ‘fiscal’ health of their corporations.

7) I am aware that many physicians are paid higher reimbursement rates for administering vaccines.

8) I am aware that LEGISLATORS for the corporation known as the STATE OF OHIO, listed on Dun and Bradstreet, vote on statutes and rules for the STATE OF OHIO. As the LEGISLATORS have no medical training and can easily be influenced by drug company lobbyists and/or the CDC, I do not accept their corporate statutory vaccination mandates as science-based.

9) I am aware of multiple scientific peer-reviewed papers that have exposed the dangers of many vaccines as well as the “herd immunity myth” of 1933.

10) I am aware that the corporation HEALTH & HUMAN SERVICES, UNITED STATES DEPARTMENT OF (listed on Dun and Bradstreet and headquartered in WASHINGTON DC) determines claims paid from the Vaccine Injury Compensation Trust Fund via a secret administrative process and also profits from vaccine patents.

11) I have concluded that failure to follow the CDC recommendations about vaccinations is less likely to endanger the health or life of my son (or daughter) or other’s sons and daughters than following their recommendations. For the reasons I have listed and more, I do not consent to anyone administering any vaccine to my son or daughter unless they provide me with the vaccine package insert, allow me to determine if the health risks are acceptable, and sign a document stating that they, in their professional and personal capacity, not me (and or my spouse) accept the responsibility for any injury or illness (as defined by the International Medical Council on Vaccination) the vaccine they administer might cause my progeny (property), Sally Doe.

NOTE: This document can be used to protect those that administer vaccines (physicians, nurses or others) or are obliged to adhere to corporate statutes from any punitive statutory actions or penalties.

Mother Signature:                               Date:

Father: Signature:                               Date:

Witness: Signature:                            Date:

Witness: Signature:                            Date:

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