Flu Vaccine Record Form – Fill Out and Use This PDF

SECTION C

I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the minor patient; or (c) the legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of Walgreens or Take Care Health ServicesSM, as applicable, to administer the vaccine(s) I have requested above. I understand that it is not possible to predict all possible side effects or complications associated with receiving vaccine(s). I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering healthcare provider. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless Walgreens or Take Care Health ServicesSM, as applicable, its staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine(s) listed above. I acknowledge that: (a) I understand the purposes/benefits of my state’s immunization registry (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) Walgreens or Take Care Health ServicesSM, as applicable, may disclose my immunization information to the State Registry, to the State HIE, or through the State HIE, to the State Registry, for purposes of public health reporting

or to my health care providers enrolled in the State Registry and/or State HIE for purposes of care coordination. I acknowledge that, depending upon my state’s law, I may prevent, by using a state-approved opt-out form or, as permitted by my state law, a Walgreens or Take Care Health ServicesSM opt-out form (“Opt-Out Form”): (a) the disclosure of my immunization information by Walgreens or Take Care Health ServicesSM to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from sharing my immunization information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. Walgreens or Take Care Health ServicesSM, as applicable, will, if my state permits, provide me with an Opt-Out Form. I understand that, depending on my state’s law, I may need to specifically consent, and to the extent required by my state’s law, by signing below, I hereby do consent to Walgreens or Take Care Health ServicesSM, as applicable, reporting my immunization information to the State HIE, or through the State HIE and/or State Registry to the entities and for the purposes described in this Informed Consent form. Unless I provide Walgreens or Take Care Health ServicesSM, as applicable, with a signed Opt-Out Form, I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed Opt-Out Form to Walgreens, Take Care Health ServicesSM and/or my State HIE, as applicable. I understand that even if I do not consent or if I withdraw my consent, my state’s laws may permit certain disclosures of my immunization information to or through the State HIE as required or permitted by law. I also authorize Walgreens or Take Care Health ServicesSM, as applicable, to disclose my, or my child’s (or unemancipated minor for whom I am authorized to act as guardian or in loco parentis) proof of immunization to the school where I am, or my child (or unemancipated minor for whom I am authorized to act as guardian or in loco parentis) is, a student or prospective student. I further authorize Walgreens or Take Care Health ServicesSM, as applicable, to (a) release my medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information, to, or through, the State HIE to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, (b) submit a claim to my insurer for the above requested items and services, and (c) request payment of authorized benefits be made on my behalf to Walgreens or Take Care Health ServicesSM, as applicable, with respect to the above requested items and services. I further agree to be fully financially responsible for any cosharing amounts, including copays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service or, if Walgreens or Take Care Health ServicesSM invoices me after the time of service, upon receipt of such invoice.

(Parent or guardian, if minor)

*Healthcare providers can be an immunization-certified pharmacist or a registered nurse, licensed practical nurse, licensed vocational nurse, nurse practitioner, physician or physicians assistant.

†Patient care services at Healthcare Clinic at select Walgreens provided by Take Care Health Services, an independently owned professional corporation whose licensed healthcare professionals are not employed by or agents of Walgreen Co. or its subsidiaries, including Take Care Health Systems, LLC. Walgreen Co. and its subsidiary companies provide management services to provider practices, in-store clinics and worksite health and wellness centers.

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First name:Last name:

Subcutaneous injection is in the upper arm (posterolateral)

Intradermal injection is in the deltoid

‡A 5/8 inch needle may be used for patients weighing less than 130 lbs (<60kg) for IM injection in the deltoid muscle only if the subcutaneous tissue is not bunched and the injection is made at a 90-degree angle.

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