CERTIFICATE OF EFFICACY

Should a physician insist that you, or your child, take treatment, insist that they first sign these documents. If they are certain that the drugs are effective, they should agree without hesistation to stand behind their recommendations and provide, in writing, their assurance for your health and safety.

Certification of Treatment Efficacy and Safety

Name of Patient:..............................................................................................Date:...............

Doctor/Clinician Instructions: Initial each statement, sign and date at bottom. Attach copy of complete treatment protocol.

As the Doctor/Clinician recommending and/or administering the attached HIV/AIDS treatment protocol, I hereby certify with a reasonable degree of scientific certainty that the pharmaceuticals prescribed:

......Will not cause or contribute to the development of immune deficiency;

......Will not cause or contribute to the development of opportunistic infections;

......Are for treatment of existing symptoms or conditions and will not be responsible for the worsening of existing symptoms or conditions, or the development of new disorders, or a decline in this patient's clinical health status.

In addition, I hereby certify that in the event it becomes known that the drugs I have prescribed are found to have contributed to or caused development of immune deficiency, the development of opportunistic infections, the worsening of existing symptoms or conditions, or the development of new disorders, that I will be liable for this patient's pain and suffering, including death.

Name of office/clinic:.................................................................

Name of physician/clinician:.......................................................

Signature of physician/clinician:.................................Date:.........

Signature of patient:.................................................Date:..........