____ 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.21
I also understand that prior to Covid-19 injection, health care providers are legally required to communicate information “consistent with the fact sheets” to patients and either provide a hard copy or direct patients to the appropriate website.
____ 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.”19
____ [U.S. only] I understand that under the 1986 National Childhood Vaccine Injury Act and the 2005 PREP Act, it will be difficult if not impossible to hold the manufacturer of this Covid-19 injection responsible for any damage to my health or death resulting from this injection.20
____ [Non-U.S.] I have reviewed the policies or agreements in place in my country regarding indemnification and compensation; I understand that depending on these policies or agreements, it may be difficult if not impossible to hold the manufacturer of this Covid-19 injection responsible for any damage to my health or for death resulting from this injection.
____ I understand that it will be difficult if not impossible to hold the health institutions, doctors, and nurses that distributed 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, state, 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 will 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.
For Families Planning on Having Additional 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.21
____ 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.22
____ AstraZeneca Covid-19 injection: I understand that this injection is produced in genetically modified human embryonic kidney cells (HEK 293).
____ My spouse has agreed 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 for examples of each; see also endnote #9).
Reasons for Taking Injection
____ I understand that Covid-19 has a statistical probability of death23 of 0.003% for youth (ages 0-19), 0.02% for those ages 20-49, 0.5% for individuals aged 50-69, and 5.4% for seniors age 70 and older.24
____ 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-19.25
____ Nevertheless, I want to take these Covid-19 injections. The reason(s) why is (are):
HEALTH CARE
____ Due to the difficulties of accessing the appropriate care in an emergency, I have identified and arranged health care providers who will be available on a timely basis in the event of a material adverse event from the Covid-19 injection:
https://pandemic.solari.com/family-financial-disclosure-form-for-covid-19-injections/ For Families Planning on Having Additional 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.21 I also understand that prior to Covid-19 injection, health care providers are legally required to communicate information “consistent with the fact sheets” to patients and either provide a hard copy or direct patients to the appropriate website.
____ 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.”19
____ [U.S. only] I understand that under the 1986 National Childhood Vaccine Injury Act and the 2005 PREP Act, it will be difficult if not impossible to hold the manufacturer of this Covid-19 injection responsible for any damage to my health or death resulting from this injection.20
____ [Non-U.S.] I have reviewed the policies or agreements in place in my country regarding indemnification and compensation; I understand that depending on these policies or agreements, it may be difficult if not impossible to hold the manufacturer of this Covid-19 injection responsible for any damage to my health or for death resulting from this injection.
____ I understand that it will be difficult if not impossible to hold the health institutions, doctors, and nurses that distributed 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, state, 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 will 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.
For Families Planning on Having Additional 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.21
____ 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.22
____ AstraZeneca Covid-19 injection: I understand that this injection is produced in genetically modified human embryonic kidney cells (HEK 293).
____ My spouse has agreed 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 for examples of each; see also endnote #9).
Reasons for Taking Injection
____ I understand that Covid-19 has a statistical probability of death23 of 0.003% for youth (ages 0-19), 0.02% for those ages 20-49, 0.5% for individuals aged 50-69, and 5.4% for seniors age 70 and older.24
____ 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-19.25
____ Nevertheless, I want to take these Covid-19 injections. The reason(s) why is (are):
HEALTH CARE
____ Due to the difficulties of accessing the appropriate care in an emergency, I have identified and arranged health care providers who will be available on a timely basis in the event of a material adverse event from the Covid-19 injection:
Covid-19 Infection