Declaration of Informed Consent Form – Covid Injection Product

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VCC – Printable Declaration of Informed Consent Covid Injection Product 2021 – PDF

Declaration of Informed Consent

Use of Experimental COVID Injection Products

Note: This document has been adapted from information compiled by Catherine Austin Fitts – Solari Report (March 1, 2021). References and the full document can be found at: https://pandemic.solari.com/family-financial-disclosure-form-for-covid-19-injections/
The following is a declaration that I am aware of the following information as pertains to the COVID-19 vaccine products available under interim approval/emergency use authorization.
In signing this document I confirm that I have completed my due diligence on the Covid-19 injection that I propose to take. I hereby confirm that:

____ I understand that this Covid-19 injection is being distributed under an ‘interim use’/ ‘emergency use authorization’ and that it has not been formally approved by Health Canada.

____ I understand that the results of Phase III safety trials will not be reported until 2022 or 2023 depending upon the injection manufacturer.

____ I understand that this Covid-19 injection is made by:

Moderna – a company that in 10 years had never brought a single product to market prior to the coronavirus vaccine [i]
Pfizer – a company with a demonstrated history of enforcement settlements for fraudulent marketing [ii]
Johnson & Johnson – a company with a demonstrated record of health care fraud [iii]
AstraZeneca – a company that paid one of the top 10 pharmaceutical company settlements ever [iv]

____ If Pfizer or Moderna: I understand that this Covid-19 injection is an experimental gene therapy.

____ I understand that the injection has only been designed to protect against moderate symptoms of Covid-19 and that it may not protect me from more severe symptoms including hospitalization and death. [v]

____  I understand that by agreeing to this injection, I may be required to take further Covid-19 injections as indicated by the manufacturer’s protocol or requirements, including potential annual “booster shots.” [vi]

____ I understand that this Covid-19 injection is not designed to address mutating versions or additional variants of the coronavirus.

____ I have read a copy of the manufacturer’s fact sheet for the Covid-19 injection (links below), which states that the injections are not Health Canada/FDA approved, describes the ingredients, outlines potential material adverse events, and acknowledges that not all risks are known.

Moderna: https://www.fda.gov/media/144638/download
Pfizer: https://www.fda.gov/media/144414/download
Johnson & Johnson: https://www.janssenlabels.com/emergency-use-authorization/Janssen+COVID-19+Vaccine-HCP-fact-sheet.pdf
AstraZeneca: https://www.gov.uk/government/publications/regulatory-approval-of-covid-19-vaccine-astrazeneca/information-for-uk-recipients-on-covid-19-vaccine-astrazeneca

____ I have reviewed the available databases of material adverse events from Covid-19 injections (see Table 2), including deaths reported to date for people who have received these injections.

____ I understand that prior to Covid-19 injection, health care providers are legally required to communicate information “consistent with the fact sheets” to patients to ensure they are giving informed consent.

____ I understand that because some of the ingredients of these Covid-19 injections are proprietary and may, therefore, be secret, the ingredients listed in the manufacturers’ fact sheets may be incomplete. I also understand that prior research on other vaccines has demonstrated the presence of nanoparticles, heavy metals, fetal tissue, and other substances not disclosed (or not fully disclosed) in “vaccinations.” [vii]

 ____ I understand that the Government of Canada has granted Covid-19 injection manufacturers legal indemnity for any harm or injury, including death, caused by their products; as a result it will be difficult if not impossible to hold the manufacturer of the Covid-19 injection responsible for any damage to my health or death resulting from this injection.

____ I understand that it will be difficult if not impossible to hold the health institutions, doctors, and nurses that administered this Covid-19 injection to me responsible for any damage to my health or for my death.

____ I understand that it will be difficult if not impossible to hold federal, provincial, and local health care officials and regulators responsible for any damage to my health from the Covid-19 injection or for my death.

____ I understand, therefore, as a practical matter that I and my closest relatives may experience and shoulder the full cost in terms of time and money of any financial adverse impact of a material adverse event resulting from my taking this Covid-19 injection.

____ I understand that while the Prime Minster of Canada announced that the federal government would implement a COVID vaccine injury compensation program to compensate Canadians injured and killed due to the injection, no details of such a program have been released and the extent of coverage is unknown.

For Families Planning on Having Children

____ Pfizer and Moderna Covid-19 injections: I understand that this injection has the potential to alter my DNA in ways that no one yet understands and that this injection could alter the DNA of my unborn children or any woman who carries my unborn children.

____ Pfizer and Moderna Covid-19 injections: I understand that knowledgeable experts have shared serious concerns in a petition filed with the European Medicines Agency that components of the Covid-19 mRNA injections could trigger an immune reaction against syncytin-1, a protein responsible for development of the placenta and essential for a successful pregnancy, resulting in potential infertility. [viii]

 ____ Johnson & Johnson Covid-19 injection: I understand that this injection is produced in genetically modified human embryonic retinal cells (PER.C6 TetR) and that the presence of fetal DNA fragment contaminants in injections has been linked to autism spectrum disorder.[ix]

____ AstraZeneca Covid-19 injection: I understand that this injection is produced in genetically modified human embryonic kidney cells (HEK 293).

____ My spouse and I agree to assume the risks of such alterations of my DNA and any impact it may have on our ability to have children or on our unborn children.

Material Adverse Events

____ I understand and have reviewed the material adverse events reported in connection with the Covid-19 injections. Known adverse events include Covid-19 infection; anaphylaxis; neurological disorders; autoimmune disorders; other long-term chronic diseases; blindness and deafness; infertility, fetal damage, miscarriage, and stillbirth; and death (see Table 1).

Risk of Death/Treatment Options

____ I understand that Covid-19 has a statistical probability of death of 0.003% for youth (ages 0-19), [x] 0.02% for those ages 20-49, 0.5% for individuals aged 50-69, and 5.4% for seniors age 70 and older. [xi]

 ____ I also understand that there are multiple, low-cost, non-injection therapeutic drug protocols for early intervention and prophylaxis that have a high rate of success in helping defend against or recover from Covid-19. [xii]

With the above understanding, I confirm that I voluntarily choose to take these Covid-19 injections and that I am under no threat of coercion or penalty for refusing to take this product.
 
___________________                                   ____________________
Name                                                                           Date
 

TABLE 1.
Examples of Adverse Events Reported Following Covid-19 Injections
Covid-19 Infection
Hundreds of Israelis get infected with Covid-19 after receiving Pfizer/ BioNTech vaccine – reports (January 1, 2021)
https://www.rt.com/news/511332-israel-vaccination-coronavirus-pfizer/
4,500 people diagnosed with COVID after getting 1st vaccine dose (January 12, 2021)
https://www.israelnationalnews.com/News/News.aspx/294794
Informed consent disclosure to vaccine trial subjects of risk of COVID-19 vaccines worsening clinical disease
https://pubmed.ncbi.nlm.nih.gov/33113270/
Anaphylaxis
VAERS COVID reports
https://www.openvaers.com/covid-data
One-third of deaths reported to CDC after COVID vaccines occurred within 48 hours of vaccination (VAERS data through February 12, 2021)
https://childrenshealthdefense.org/defender/latest-data-cdc-vaers/
COVID vaccine injury reports grow in number, but trends remain consistent (March 5, 2021)
https://childrenshealthdefense.org/defender/vaers-covid-vaccine-injury-reports-increase/
FDA investigates allergic reactions to Pfizer COVID vaccine after more healthcare workers hospitalized (December 21, 2020)
https://childrenshealthdefense.org/defender/fda-investigates-reactions-pfizer-covid-vaccine-healthcare-workers-hospitalized/
Metro healthcare worker describes severe allergic reaction to COVID-19 vaccine (January 14, 2021)
https://fox4kc.com/tracking-coronavirus/important-information-to-know-after-metro-healthcare-worker-suffers-severe-allergic-reaction-from-covid-19-vaccine/
California shelves batch of Moderna vaccines over allergy concerns (January 18, 2021)
https://nypost.com/2021/01/18/california-shelves-batch-of-vaccines-over-allergy-concerns/
I took the Moderna mRNA vaccine without doing my own research (February 19, 2021)
https://www.bitchute.com/video/1lyFggcw9P9c/
Louisiana woman convulsing after Pfizer experimental Covid vaccine (January 14, 2021)
https://www.bitchute.com/video/YoJLKtbksyKv/
The intertwined history of myelitis and vaccines [AstraZeneca/Oxford] (September 25, 2020)
https://childrenshealthdefense.org/news/the-intertwined-history-of-myelitis-and-vaccines/
Autoimmune Disorders
Professor and molecular genetics expert Dolores Cahill expects autoimmune reactions to result from the mRNA injections “months later,” stating that “this gene therapy…is setting up an autoimmune disease chronically.”
https://www.lewrockwell.com/2021/01/bill-sardi/horrific-latent-deaths-predicted-among-the-elderly-by-genetics-professor-after-immunization-with-rna-vaccines/
Immunologist Bart Classen—who has been issuing warnings for years about chronic, late-occurring adverse events from vaccination—is concerned that the mRNA injections could create new mechanisms of vaccine adverse events. Classen notes that adverse events such as type 1 diabetes “may not occur until 3-4 years after a vaccine is administered.”
https://scivisionpub.com/pdfs/covid19-rna-based-vaccines-and-the-risk-of-prion-disease-1503.pdf
Are we on the verge of a “super-epidemic” of autoimmune diseases? (February 19, 2021)
https://childrenshealthdefense.org/defender/super-epidemic-autoimmune-diseases/
Vaccination and autoimmune diseases: is prevention of adverse health effects on the horizon? (July 20, 2017)
https://link.springer.com/article/10.1007/s13167-017-0101-y
The intertwined history of myelitis and vaccines [AstraZeneca clinical trial participant diagnosed with multiple sclerosis] (September 25, 2020)
https://childrenshealthdefense.org/news/the-intertwined-history-of-myelitis-and-vaccines/
Long-term Chronic Disease
Immunologist Bart Classen—who has been issuing warnings for years about chronic, late-occurring adverse events from vaccination—is concerned that the mRNA injections could create new mechanisms of vaccine adverse events. Classen notes that adverse events such as type 1 diabetes “may not occur until 3-4 years after a vaccine is administered.”
https://scivisionpub.com/pdfs/covid19-rna-based-vaccines-and-the-risk-of-prion-disease-1503.pdf
32-year-old Mexican doctor suffers seizures and is paralyzed after receiving the Pfizer experimental vaccine (December 30, 2020)
https://vaccineimpact.com/2021/32-year-old-mexican-doctor-suffers-seizures-and-is-paralyzed-after-receiving-the-pfizer-experimental-vaccine/
Blindness and Deafness
United Kingdom: 12 people deaf, five blind after Pfizer BioNTech mRNA shots (February 11, 2021)
https://thecovidblog.com/2021/02/16/united-kingdom-12-deaf-five-blind-after-pfizer-mrna-shots/
Infertility, Fetal Damage, Miscarriage, and Stillbirth (women only)
Eight unborn babies dead soon after their mothers received COVID-19 vaccine (as of January 22, 2021) https://www.preciouslife.com/news/965/eight-unborn-babies-dead-soon-aftertheir-mothers-received-covid19-vaccine/
Sara Beltrán Ponce: Wisconsin resident doctor has miscarriage days after COVID “vaccine” (February 7, 2021)
https://thecovidblog.com/2021/02/07/sara-beltran-ponce-wisconsin-resident-doctor-has-miscarriage-days-after-covid-vaccine/
Health officials push pregnant women to get COVID shots, despite known risks (February 23, 2021)
https://childrenshealthdefense.org/defender/health-officials-push-pregnant-women-covid-vaccine/?itm_term=home
Death
Johns Hopkins scientist: “A medical certainty” Pfizer vaccine caused death of Florida doctor (January 3, 2021)
https://childrenshealthdefense.org/defender/johns-hopkins-scientist-medical-certainty-pfizer-vaccine-caused-death-florida-doctor/
Sara Stickles: 28-year-old has brain aneurysm, dead five days after second Pfizer mRNA shot (February 12, 2021)
https://thecovidblog.com/2021/02/12/sara-stickles-28-year-old-has-brain-aneurysm-dead-days-after-second-pfizer-mrna-shot/
Death of pediatric assistant two days after receiving Covid vaccine puts Portuguese health authorities “on alert” (January 1, 2021)
https://www.portugalresident.com/death-of-pediatric-assistant-two-days-after-receiving-covid-vaccine-puts-portuguese-health-authorities-on-alert/
Dottore si vaccina in diretta TV e muore dopo pochi giorni, ma “non di Covid” [Doctor gets vaccinated on live TV and dies a few days later, but “not of Covid”] (February 27, 2021)
https://www.rassegnastampa.eu/video/dottore-si-vaccina-in-diretta-tv-e-muore-dopo-pochi-giorni/
One-third of deaths reported to CDC after COVID vaccines occurred within 48 hours of vaccination (VAERS reports through February 12, 2021)
https://childrenshealthdefense.org/defender/latest-data-cdc-vaers/
Experimental vaccine death rate for Israel’s elderly 40 times higher than COVID-19 deaths: researchers (March 1, 2021)
https://www.lifesitenews.com/news/experimental-vaccine-death-rate-for-israels-elderly-40-times-higher-than-covid-19-deaths-researchers
UK data show 402 reports of deaths following COVID vaccines (March 2, 2021)
https://childrenshealthdefense.org/defender/uk-data-deaths-following-covid-vaccines/
 
TABLE 2.
Public Databases Compiling Reports of Adverse Events
UK Medical Freedom Alliance (UKMFA) (global)
See UKMFA Collated Data – Adverse Reactions Summary document https://www.ukmedfreedom.org/resources/covid-19-vaccine-info
Vaccine Adverse Event Reporting System (VAERS), U.S. Department of Health and Human Services
The Vaccine Adverse Event Reporting System (VAERS) is a highly flawed voluntary reporting system co- administered by the CDC and FDA. Dr. Sherri Tenpenny estimates that reporting of adverse events to VAERS represents approximately 10% of actual adverse events. A Harvard study commissioned in 2010 by the federal government produced an even lower estimate, stating that less than 1% of adverse events get reported:
https://digital.ahrq.gov/sites/default/files/docs/publication/r18hs017045-lazarus-final-report-2011.pdf
VAERS reports are accessible through the CDC Wonder search engine or through the more user-friendly MedAlerts search engine maintained by the National Vaccine Information Center (NVIC). MedAlerts also offers more powerful search capabilities and more extensive reporting.
https://vaers.hhs.gov
https://wonder.cdc.gov/vaers.html
https://www.medalerts.org/
VaxxTracker
VaxxTracker describes itself as a “repository for vaccine adverse effects.” The site collects adverse event reports and provides data summaries with monthly counts, top 10 reaction types, outcomes, descriptions of symptoms, and more. https://www.vaxxtracker.com/VaxDefault.asp
Children’s Health Defense
Children’s Health Defense encourages those who experience vaccine injuries to report the adverse event to VAERS and vaxxtracker.com as well as to Children’s Health Defense.
https://childrenshealthdefense.org/defender/injured-by-vaccine-how-to-report-it/
The Informed Consent Action Network
ICAN also collects reports of Covid-19 vaccine injuries. Recognizing that “Potential safety issues may not be disclosed or fully disclosed to individuals receiving these experimental products,” ICAN can “assist in investigating whether [individuals] have been adequately warned of the potential injury.” https://www.icandecide.org/report-a-covid-19-vaccine-injury/
EudraVigilance
The European Medicines Agency maintains a database of suspected adverse drug reactions that is accessible to the general public (see box for “Healthcare professionals, patients and the general public”). Under the letter “C,” Covid-19 reports can be generated for the Moderna, Pfizer, and AstraZeneca injections. As of February 23, 2021, EudraVigilance had received over 71,000 suspected adverse reaction reports for the Pfizer injection, almost 9,000 for the AstraZeneca injection, and over 2,500 for the Moderna injection.
https://www.ema.europa.eu/en/human-regulatory/research-development/pharmacovigilance/eudravigilance/access-eudravigilance-data
 
Refererences
[i] See Motley Fool’s three “red flags”:
https://www.fool.com/investing/2020/08/29/3-red-flags-for-modernas-potential-coronavirus-vac/
In the company’s briefing document reviewed by the FDA :
https://www.fda.gov/media/144452/download,
page 15, tables 7 and 8), Moderna admits to a *23.9%* rate of adverse events. Among the 15,185 people in the study, there were 3,632 adverse events in the first 28 days, statistics that do not include the longer-term effects of DNA modification, infertility, autoimmunity, etc.
[ii] See “Softball Pfizer vaccine rollout interview goes horribly wrong”:
https://www.youtube.com/watch?v=LMAZJtOdYNI
[iii] Johnson & Johnson is facing billions in payouts for marketing baby powder known for decades to be tainted with cancer-causing asbestos. See, for example:
https://markets.businessinsider.com/news/stocks/johnson-johnson-sets-aside-3-9-bln-for-baby-powder-verdict-settlements-1030109923?op=1
For details on health care fraud related to Risperdal and other drugs, see:
https://www.cbsnews.com/news/johnson-johnson-to-pay-22b-in-us-health-care-fraud-settlement/
[iv] AstraZeneca paid the settlement after illegally marketing an anti-psychotic drug to children and the elderly. See: https://www.enjuris.com/blog/resources/largest-pharmaceutical-settlements-lawsuits/.
[v] See Peter Doshi and Eric Topol, “These coronavirus trials don’t answer the one question we need to know,” The New York Times, September 22, 2020. We may not find out whether the vaccines prevent moderate or severe cases of Covid-19.
https://www.nytimes.com/2020/09/22/opinion/covid-vaccine-coronavirus.html
[vi] https://childrenshealthdefense.org/defender/pfizer-ceo-annual-vaccine-covid/.
[vii] In 2017, Italian researchers reviewed the ingredients of 44 types of so-called “vaccines.” They discovered heavy metal debris and biological contamination in every human vaccine they tested. The researchers stated, “The quantity of foreign bodies detected and, in some cases, their unusual chemical compositions baffled us.” They then drew the obvious conclusion, namely, that because the micro- and Nano contaminants were “neither biocompatible nor biodegradable,” they were “biopersistent” and could cause inflammatory effects right away—or later. From, “The Injection Fraud: It’s Not a Vaccine” by Catherine Austin Fitts:
https://childrenshealthdefense.org/news/editorial/the-injection-fraud-its-not-a-vaccine/
Analyses of aborted fetal cell lines in “vaccines” identified abnormal human DNA, including genes associated with cancer, in all samples analyzed in quantities “up to 300 times higher than the limit imposed by the [European Medicines Agency] for carcinogenic DNA.” From, “New data shows DNA from aborted fetal cell lines in vaccines” by the Corvelva team,
https://childrenshealthdefense.org/news/new-data-shows-aborted-fetal-cells-in-vaccines/
[viii]
https://dryburgh.com/wp-content/uploads/2020/12/Wodarg_Yeadon_EMA_Petition_Pfizer_Trial_FINAL_01DEC2020_signed_with_Exhibits_geschwarzt.pdf
[ix] Theresa Deisher et al., “Epidemiologic and molecular relationship between vaccine manufacture and autism spectrum disorder prevalence,”
https://pubmed.ncbi.nlm.nih.gov/26103708
[x] See Table 1 in https://www.cdc.gov/coronavirus/2019-ncov/hcp/planning-scenarios.html
[xi] See CDC statistics here: https://www.cdc.gov/nchs/nvss/vsrr/covid_weekly/index.htm#SexAndAge
Additional sources of statistics can be found at Swiss Policy Research (https://swprs.org/facts-aboutcovid-19 and Children’s Health Defense (https://childrenshealthdefense.org)
[xii] See, for example, “Review of the emerging evidence demonstrating the efficacy of ivermectin in the prophylaxis and treatment of COVID-19”: https://journals.lww.com/americantherapeutics/fulltext/2021/00000/review_of_the_emerging_evidence_demonstrating_the.4.aspx.
 

Vaccine Choice Canada is committed to providing accurate, up-to-date information related to vaccination. Should you identity information in this document by that is inaccurate or not current, we ask that you identify the specific information and provide references or documentation to enable us to make the necessary corrections. Please send this information to:  info@vaccinechoicecanada.com