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Question	Answer
Form Name	Walgreens Form Administration Record
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	walgreens var form, vaccination consent form walgreens, walgreens form consent vaccination, vaccination consent form for walgreens

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Vaccine Administration Record (VAR) Informed Consent for Vaccination*

IMMUNIZATION

LOCATION

SECTION A

Please print clearly.

Home Phone

Date of Birth

Age

Gender

Male

Female

First Name

Last Name

Home Address

City

State

ZIP Code

Email Address

Medicare Part B Number (if applicable)

Primary Care Physician/Provider Name (if known)

Physician/Provider Phone

Physician/Provider Address

City

State

SECTION B The following questions will help us determine your eligibility to be vaccinated today.

YES

DON’T

KNOW

1. Which vaccines are you requesting to have administered today? Please check all requested vaccines:

Flu Shot

Flu Nasal Spray (live — ages 2–49 only)

Flu HD (ages 65+)

Pneumonia

Shingles

Other

2. Do you feel sick today?

3. Do you have allergies to medications, food or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol or thimerosal)

If yes, please list the allergies:

4. Have you received any vaccinations or skin tests in the past four weeks? If yes, please list the vaccination.

VACCINES

5. Have you ever had a serious reaction to an inﬂuenza vaccine or any other vaccine in the past?

6. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or

other nervous system problem?

7. Are you 65 years of age or older?

ALL

8. Do you smoke?

9. Do you have a chronic condition or long-term health problem? If yes, please check all that apply.

Other

Anemia

Asthma

Diabetes

Heart disease

Kidney disease

Liver disease

Lung disease

10. If you answered YES to question #7, 8 or 9, have you ever had a pneumonia vaccination?

11. Have you ever had a shingles vaccination (for patients 60 years of age and older only)?

12. Are you a healthcare worker?

13. For women: Are you pregnant or considering becoming pregnant in the next month?

14. Are you currently on home infusions, weekly injections, steroid therapy, anticancer drugs or radiation treatments?

VACCINES

17. Are you receiving aspirin therapy or aspirin-containing therapy? (18 years of age and younger only)

15. Do you have cancer, leukemia, lymphoma, HIV/AIDS or any other immune system disorder or are you in contact with anyone who has a severely

weakened immune system?

16. Have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin in the past year?

LIVE

18. If the patient receiving vaccine is under 5 years old, is there a history of asthma or wheezing? (for FluMist® only)

19. Does the patient have a nasal condition serious enough to make breathing difﬁcult, such as a very stuffy nose? (for FluMist® only)

SECTION C

I certify that I am: (i) the patient and at least 18 years of age; (ii) the parent or legal guardian of the minor patient; or (iii) 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: I understand the purposes/beneﬁts of my state’s immunization registry (“State Registry”). I acknowledge that, depending upon my state law, I may prevent, by using a state-approved opt-out form (“Opt-Out Form”): (a) disclosure of my immunization information to the State Registry; or (b) the State Registry from sharing my immunization information with any of my other healthcare providers enrolled in the State Registry. Walgreens or Take Care Health ServicesSM, as applicable, will, if my state permits, provide me with an Opt-Out Form. Unless I provide Walgreens or Take Care Health ServicesSM, as applicable, with a signed Opt-Out Form, I elect to participate fully in, and consent to Walgreens or Take Care Health ServicesSM, as applicable, reporting my immunization information to the State Registry.

I authorize Walgreens or Take Care Health ServicesSM, as applicable, to (1) release my medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information, to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, (2) submit a claim to my insurer for the above requested items and services, and (3) 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.

Patient Signature:

Date:

(Parent or Guardian, if minor)

SECTION D (HEALTH CARE PROVIDERS ONLY) The following section is to be completed by the health care provider only.

Immunizer Name (print): ________________________________ Immunizer Signature: _____________________________ RPh/PharmD/RN/LPN/LVN/NP/PA (circle one)
If applicable, Intern Name (print): _________________________________ Administration Date: ______________________ Date VIS given to Patient: _________________
Vaccine		Lot #	Exp Date	Manufacturer	Dosage	Circle Site of Injection	VIS Date	RPh Pre-ﬁll Initials

Inactivated inluenza	-PF				0.5 ml	L / R Deltoid IM

*Healthcare providers can be an immunization-certiﬁed pharmacist or a registered nurse, licensed practical nurse, licensed vocational nurse, nurse practitioner or physician’s assistant.
**Patient care services at Take Care Clinics are provided by Take Care Health ServicesSM, 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 SystemsSM, LLC.	12FL0001

12FL0001_VAR_FORM_COBRANDED.INDD 1

7/3/12 11:21 AM

Walgreens Form Administration Record – Fill Out and Use

Walgreens Administration Vaccination Details

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