From David Icke`s website page 3 of 3

[Northern Boy]

In the event of mandatory Vaccination bring this form with you and have your doctor sign it before you make your decision to receive the shot. There are 3 pages each one I will have to upload separate as they are too big for the upload limit

Page 3


lawsuits in the instant case. I issue this document of my own free will after consultation with competent legal counsel whose name is _____________________________, an attorney admitted to the Bar in the State of __________________ .
__________________________________ (Name of Attending Physician)
__________________________________ L.S. (Signature of Attending Physician)
Signed on this _______ day of ______________ A.D. ________
Witness: _______________________________ Date: _____________________
Notary Public: ___________________________Date: ______________________