Vaccine Liability Acceptance Form

I, _______________________________________________________ (Name of the

Physician administering the vaccine), hereby declare under penalty of perjury and
upon my full commercial liability that the vaccine I am about to administer is safe
and efficacious and that I shall be held personally liable both legally and financially
for any bodily injury or mental harm that may occur to my patient baby’s name, due
to my injecting him with the vaccine ____________________________.

Bodily injury includes any injury to the body, sickness or disease, including but not
limited to death resulting from any of these at any time, and if arising out of the
foregoing, mental anguish, mental injury, disability, shock or fright.

I attest that I have been made aware of the risk of serious side-effects of the vaccine
I am administering to my patient.

______________________________ (Sign on this line) Dated: ________________

Subscribed and affirmed, or sworn to before me in the County of _________________,

State of Colorado, this ___________ day of ________________, 2018.
My Commission Expires: __________________

_____________________________
Notary Public