1WAIVER OF LIABILITY

PROHIBITING ADMINISTRATION OF VITAMIN K INJECTION

As parents and legal guardians, we, Jamie and Jason Steward do hereby waive our right to hold
Glenwood Medical Center and/or its faculty liable for any illness, trauma, or other non-typical medical
condition resulting from our refusal to allow intravenous, intramuscular, or any other method of
administration of vitamin K to our newborn.

We believe this practice to be very harmful and unnecessary when used as a prophylactic to treat
a disease that can not exist. This will be a controlled cesarean delivery and will not employ the use of
forceps, contractions, or other methods of extruding the fetus that would increase the likelihood of internal
hemorrhaging. Furthermore, studies have demonstrated there is no medical benefit to this procedure.
Modern science has revealed babies are not born with a vitamin K deficiency unless the mother is
malnourished, has taken antibiotics throughout pregnancy, or has a history of drug abuse.

Studies have shown there is no significant difference in the occurrence of spontaneous brain
hemorrhages in babies given vitamin K injections and those who were not. Further studies have
demonstrated a significant increase in the occurrence of childhood leukemia, autism, and behavioral
disorders when administered vitamin K at birth. Most importantly, the number of jaundice cases and
deaths due to organ failure has encouraged other civilized countries to refrain from standardized use.

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JASON R. STEWARD DATE

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JAMIE D. STEWARD DATE

As the pediatrician, I agree to allow the parents to refuse this treatment on behalf of their child. By
signing below, I authorize the hospital to respect this decision but do not endorse nor provide medical
reasons to refuse the Vitamin K administration.

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Dr. Bimle DATE