NOTICE OF REFUSAL TO OFFER INFORMED CONSENT

TO CERTAIN MEDICAL PROCEDURES

In general, this is a notice to all medical providers, employers, government officials, health agencies and others, that my
“informed consent” is specific to only those procedures and treatments to which I offer my consent in writing. Claims of
my consent which are not offered by me in written form, are invalid.

WHEREAS credible public information suggests that the virus labeled COVID19, to include all alleged variants, is a “gain
of function” strain of the corona virus created in and released from a “gain of function” bioweapons lab in Wuhan,
China;

WHEREAS there has been an ongoing concerted effort to conceal public access to information related to the true nature
of, and lethal impact of, all existing COVID19 injections, making “informed consent” impossible due to the intentional
withholding of information necessary to offer any consent;

WHEREAS publicly released VAERS REPORTS have shown significant lethal health effects in a large group of humans who
have received any of the labeled COVID19 “vaccines,” especially those designed upon mRNA experimental injections;

WHEREAS recent credible public reports are showing that 99.9% of all current COVID19 related illness, injury, and
deaths, are being found in the vaccinated population and not the unvaccinated population;

And WHEREAS no person, professional, employer, government official, court, foreign agency, health agency, or private
organization, including but not limited to, W.H.O., U.N., the CDC, NATO, IMF, WEF, possess any power, right or lawful
authority to force or coerce any health procedure upon any free person;

I hereby decline any “informed consent” for the following COVID19 related protocols;

• COVID19 (PCR) testing

• Forced or Coerced Masking
• Forced or Coerced Social Distancing
• Forced or Coerced Vaccinations
• Forced or Coerced Involuntary Lockdown
• Threats of, or any form of Deprivation of Natural Rights

FURTHER, as no legal authority exists to force or coerce these things upon any free person, any attempt to do so is a
direct unconstitutional violation of U.S. Law under 18 U.S. Code § 242 - Deprivation of rights under color of law. Any
effort to ignore or circumvent this notice will be interpreted and prosecuted as a clear intent to Deprive me of my
Natural Rights under color of law.

By signing below, you acknowledge that you have been so advised, and that you understand the information provided as
it pertains to the limited authority you have been granted under my consent.

_______________ ___________________________
DATE PRESENTER SIGNATURE

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DATE CAREGIVER SIGNATURE OFFICIAL CAPACITY

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EMPLOYER ADDRESS PHONE