Medical Declaration of Vaccination

(Vaccination certificate)
The undersigned medical doctor
Name:
__________________________________________________________________________
Address:
__________________________________________________________________________
hereby authentically confirmed, that the vaccine:
__________________________________________________________________________
Manufacturer Name:
__________________________________________________________________________
Batch number:
__________________________________________________________________________
As prevention of the following disease (s): ________________________________________
__________________________________________________________________________
was administered and consists of the following ingredients: __________________________
__________________________________________________________________________
__________________________________________________________________________
This serum/sera is/are free from any possible pollution of all kinds.
given to (name, first name)
__________________________________________________________________________
Address: __________________________________________________________________
Date of birth, social insurance#:
__________________________________________________________________________
According my diagnosis I further certify that at the time of vaccination the vaccinated
was perfect condition of health:
I found no neurological disorders such as cramps, as well as no allergies.
I confirm that the administered vaccine is completely safe for the life and health of the
vaccinated, is not and can not cause direct or indirect injury or sequelae, such as
paralysis, brain damage, blindness, tuberculosis, cancer, kidney damage, liver damage,
diabetes, etc., with (or without) fatal consequences.
I further certify that the administered vaccine will prevent the reason for vaccination for
______ year / s.
However, if any adverse reactions at this time to emerge, I will be fully liable for the damage
without delay on the part of my professional career, yet, as the policyholder, or my
family / heirs / successors.
This applies immediately and in full directly to the patient and for possible care expenses of
any nearest related person.
The patient, as also commonly responsible parent, guardian / custodian and partner / were
fully informed about the administration of vaccine and any risks of vaccinations / cleared up!
Signature of / the patient / patient or parents, guardian, trustee, partner, as a confirmation
of receipt of a general understandable vaccination-enlightenment by the attending
medicating physician:

As a treating physician, I have read and understood this vaccination certificate, BEFORE
administering a vaccination / immunization series, noted and signed the document:
Place, date, name and legally binding personal signature of the authorizes vaccinator:
official stamp: