• This form is HIPAA-compliant and your data is fully secure. Any private information shared with us is kept strictly confidential and is never shared with anyone.

     

    VACCINE EXEMPTION INFORMED CONSENT 

     

  • After completing the vaccine exemption paperwork you will be forwarded to our new patient registration form. We can only complete vaccine exemptions for those who register as patients in our practice, so this is a requirement and does not change the fee in any way.

  • Format: (000) 000-0000.
  • Dr. Haider's COVID waiver in {state} has expired, and he is awaiting his permanent license. Meanwhile, just because you live in {state} doesn't mean you can't get a Vaccine exemption written. When he "sees" you and writes your Vaccine exemption, as long as you are in one of the states where he has a license, he can legally write it and even send it to your local pharmacy.

    We don't need to see proof of travel, as many people have asked, and your word is sufficient! All you have to do is tell us which state you'll be visiting or passing through below.

  • We cannot write vaccine exemptions for those currently present in NY and CA.

  • This form is HIPAA-compliant and your data is fully secure. Any private information shared with us is kept strictly confidential and is never shared with anyone.

  • VERY IMPORTANT TO UNDERSTAND

     

    In general, a medical vaccine exemption is given by physicians and accepted by authorities when patients have a history of severe allergic reactions to components of the vaccine (e.g., PEG (over the counter MiraLAX), polysorbate or other component), or a severe reaction to prior vaccination. General or specific allergic reactions to other substances unrelated to the vaccines, even when severe, are not considered a reason to avoid vaccination.

    IF the prior reaction is to a component on a vaccine, then this will preclude all future vaccines because as of this writing all vaccines contain one or the other ingredient, and these ingredients are considered to cross react, for example, if someone is allergic to PEG, they cannot take a vaccine with either PEG or polysorbate in it and vice versa.

    IF the prior reaction is to a specific vaccine and no further testing has been done to determine if the allergy is to PEG, polysorbate or other specific component, then an exemption will only be able to prevent future vaccination doses with the vaccine that caused a reaction. The exemption will not be able to preclude the use of a different vaccine unless you get tested and show a reaction to PEG, Polysorbate or that specific component. Each case will be evaluated individually.

    VACCINE EXEMPTION REQUIREMENTS

    1. Vaccine exemption letters will ONLY be written to patients that can provide documentation of the following:
      1. Severe allergic reaction to polyethylene glycol (PEG), polysorbate or any other component of the vaccine, eg. a patient that has had a severe reaction to Miralax (AKA PEG) taken over the counter for constipation or skin prick reaction to PEG, polysorbate or other constituent chemical. In order to prove this, the patient will have to provide some form of documentation, for example: 
        1. Emergency Room reports, previous doctor's notes or medical records.
          OR
        2. A photo of an allergic rash (similar to what might appear when scratching the skin repeatedly) or any other photographic or video evidence the patient may have along with a personal report of severe symptoms like: severe difficulty breathing, sensation of throat closing up, itching, lightheadedness, passing out, along with an explanation for why this episode was not treated in an ER, Urgent Care or doctors office and thus no further documentation is available.
      2. Prior documented severe reaction to a vaccine (this will be a limited vaccine exemption as described above as it will only apply to the specific vaccine that the patient had a reaction to). The patient must provide documentary evidence similar to the evidence listed above.
    2. Vaccine exemptions will NOT be written for use in the States of New York and California.
    3. NO religious exemptions will be written. Please contact your local religious authority for those if required.

    WARNING

    We can NOT guarantee that this Vaccine Exemption Letter will be accepted. Some employers may not accept this vaccine exemption letter, although it has been written by Dr. Haider, who is a board certified and licensed Internal Medicine physician. For example, we had a case in which a particularly picky employer asked a patient to get a written exemption from an allergy specialist. If this occurs we can forward your exemption to another specialist and they may be willing to reiterate the same exemption, however they may require independent testing and verification depending on the strength of your documentation, which we have no control over. 

  • This form is HIPAA-compliant and your data is fully secure. Any private information shared with us is kept strictly confidential and is never shared with anyone.

  • INFORMED CONSENT

    You must review the below information in order to inform yourself of the mainstream consensus view as well as opposing views which are deemed to be misinformation or disinformation by mainstream authorities like the FDA and CDC. The inclusion of any information, misinformation or disinformation below should not be taken as an endorsement of that information, misinformation or disinformation. 

    Mainstream/Official consensus:

    CDC website recommends vaccination for anyone 12 and over:

    https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/adolescents.html

    CDC:  Benefits of vaccination:

    https://www.cdc.gov/coronavirus/2019-ncov/vaccines/vaccine-benefits.html

    Myths and Facts on vaccines from the CDC:

    https://www.cdc.gov/coronavirus/2019-ncov/vaccines/facts.html

    Opposing Views on Vaccination Which are Considered to be Misinformation and Disinformation by mainstream authorities:

    https://childrenshealthdefense.org/vaccinesafety/

    https://www.paulthomasmd.com/research - hovering over the research tab at the top of the screen shows a dropdown list of research topics on vaccines. 

    Steve Kirsch's article on COVID vaccine issues:

    https://trialsitenews.com/should-you-get-vaccinated/

    Dark Horse podcast with Robert Malone and Steve Kirsch:

     https://childrenshealthdefense.org/defender/censored-dark-horse-podcast-bret-weinstein-robert-malone-inventor-mrna-vaccine-technology/ 

    -Disease-causing spike protein and lipid nanoparticles leave the site of injection to concentrate in the bone marrow and ovaries. This could cause long-term effects on recipients or the children of the women injected.

    Interview of Robert Malone, inventor of the mRNA vaccine technology.

    https://www.theepochtimes.com/dr-robert-malone-mrna-vaccine-inventor-on-the-bioethics-of-experimental-vaccines-and-the-ultimate-gaslighting_3889805.html

    According to the FDA vaccines are safe and effective. The following is a list of previously FDA approved medications which were thought to be safe for many years and sometimes for decades before later being withdrawn from the market due to serious harms inflicted:


    VIOXX 

    THALIDOMIDE 

    QUAALUDES 

    DARVOCET 

    DIETHYLSTILBESTROL (DES)

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  • We can only write exemptions for existing patients in our practice, please click CONTINUE to fill out our Registration form.

    Note: Please wait after submitting the form until you are transferred to our Registration form as it may take a few moments and appear nothing is happening.

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