Walgreens Form Administration Record PDF Details

Walgreens is a pharmacy and retail store that has been in business since 1901. They offer a variety of services to their customers, including prescription medications, health and wellness products, and photo printing. One of the functions Walgreens provides its customers is the ability to fill out forms electronically. The Walgreens Form Administration Record is an electronic form that allows customers to upload or enter information into a secure database. This form can be used for a variety of purposes, such as registrations, surveys, applications, and orders. The form can be filled out on a computer or mobile device. Once the form is complete, it can be submitted electronically or printed for delivery.

You will see info about the type of form you intend to fill out in the table. It can show you the time you will require to complete walgreens form administration record, exactly what parts you will have to fill in, and so forth.

QuestionAnswer
Form NameWalgreens Form Administration Record
Form Length2 pages
Fillable?Yes
Fillable fields210
Avg. time to fill out21 min 17 sec
Other namesvaccination consent form walgreens, walgreens form consent vaccination, walgreens var forms, walgreens vaccination consent form

Form Preview Example

Vaccine Administration Record (VAR)—Informed Consent for Vaccination

Store number:

 

 

 

 

 

 

 

 

 

Rx number:

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Store address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION A

Please print clearly.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last name:

 

 

 

 

Date of birth:

Age:

Gender: Female Male

Phone:

Home address:-=

-----------

=

---=~-----~=-=-=City:-=-=--=--=-=

I wish to receive text message alerts regarding my prescriptions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

ZIP code:

 

 

 

 

Email address:

 

 

 

 

Race: American Indian or Alaska Native

Asian Native Hawaiian or Other Pacific Islander

Black or African American White

 

Other Race

 

 

 

 

 

 

 

 

Unknown

 

 

 

Ethnicity:

Hispanic or Latino Not Hispanic or Latino

Unknown ethnicity

 

 

 

Walgreens will send vaccination information from this visit to your doctor/primary care provider using the contact information provided below.

Doctor/primary care provider name:

 

 

 

 

Phone:

 

 

 

 

 

 

Address:

 

 

City:

 

 

State:

 

 

ZIP code:

 

 

I want to receive the following vaccination(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

SECTION B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All vaccines

 

 

 

 

 

 

 

 

 

 

 

 

1.

Do you feel sick today?

 

 

 

 

 

 

 

Yes

No

Don’t know

2.

Have you been diagnosed with or tested positive for COVID-19 in the last 14 days?

 

 

 

 

Yes

No

Don’t know

3.

In the past 14 days have you been identified as a close contact to someone with COVID-19?

 

 

 

 

Yes

No

Don’t know

4.

Do you have any chronic health condition such as cancer, chronic kidney disease, chronic lung disease, obesity, sickle cell disease,

Yes

No

Don’t know

 

 

diabetes, asthma or heart disease?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, please list:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Do you have a history of allergic reaction or allergies to latex, medications, food or vaccines (examples: polyethylene glycol,

Yes

No

Don’t know

 

 

polysorbate, eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)?

 

 

 

 

 

 

 

 

 

 

 

If yes, please list:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Have you ever had a reaction after receiving a vaccination, including fainting or feeling dizzy?

 

 

 

 

Yes

No

Don’t know

7.

Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré syndrome

Yes

No

Don’t know

 

 

(a condition that causes paralysis) or other nervous system problem?

 

 

 

 

 

 

 

 

 

8.

Have you received any vaccinations or skin tests in the past eight weeks?

 

 

 

 

Yes

No

Don’t know

 

 

If yes, please list:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.Have you ever received the following vaccinations?

 

 

Pneumonia: Date received

 

Shingles: Date received

 

Whooping cough: Date received

 

 

 

 

 

 

 

 

 

10

 

Do you consider yourself to be, or have you ever been told by a physician that you are, immunosuppressed?

Yes

No

Don’t know

 

11.

 

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

 

Yes

No

Don’t know

 

12.

 

For COVID-19 vaccine only: Have you been treated with antibody therapy specifically for COVID-19 (monoclonal antibodies

Yes

No

Don’t know

 

 

 

or convalescent plasma)?

 

 

 

 

 

 

 

 

 

For chickenpox, MMR® II, shingles, Vaxchora®, yellow fever only:

 

 

 

 

 

 

 

Answer the following questions only if you are receiving any vaccinations listed above.

 

 

 

 

 

13.

 

Do you have a condition that may weaken your immune system (e.g., cancer, leukemia, lymphoma, HIV/AIDS, transplant)?

Yes

No

Don’t know

 

14.

 

Are you currently on home infusions, weekly injections such as Humira® (adalimumab), Remicade® (infliximab) or Enbrel®

Yes

No

Don’t know

 

 

 

(etanercept), high-dose methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs or radiation treatments?

 

 

 

 

15.

 

Are you currently taking high-dose steroid therapy (prednisone > 20mg/day or equivalent) for longer than 2 weeks?

Yes

No

Don’t know

 

16.

 

Have you received a transfusion of blood or blood products or been given a medication called immune (gamma) globulin

Yes

No

Don’t know

 

 

 

in the past year?

 

 

 

 

 

 

 

17.

 

Do you have a history of thymus disease (including myasthenia gravis, DiGeorge syndrome or thymoma), or had your

Yes

No

Don’t know

 

 

 

thymus removed? (yellow fever only)

 

 

 

 

 

 

 

18.

 

Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only)

 

Yes

No

Don’t know

 

19.

 

Have you consumed any food or drink in the last hour? (Vaxchora® only)

 

Yes

No

Don’t know

 

20.

 

Have you taken antibiotics in the last 14 days or antimalarials in the last 10 days? (Vaxchora® only)

 

Yes

No

Don’t know

 

SECTION C

I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient; or (c) a person authorized to consent on behalf of the patient where the patient is not otherwise competent or unable to consent for themselves. Further, I hereby give my consent to Walgreens or Duane Reade and the licensed healthcare professional administering the vaccine, as applicable (each an “applicable Provider”), 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 EUA Fact Sheet 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 that the patient should remain near the vaccination location for observation for approximately 15 minutes after administration. On behalf of the patient, the patient’s heirs and personal representatives, I hereby release and hold harmless each applicable Provider, 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 vaccination registry (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) the applicable Provider may disclose my vaccination information to the State Registry, to the State HIE, or through the State HIE to the State Registry, or to any state or federal governmental agencies or authorities (“Government Agencies”), such as state, county, or local Departments of Health or the federal Department of Health and Human Services, the Centers for Disease Control and Prevention, or their respective designees as may be required by law, for purposes of public health reporting, or to my healthcare 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, an opt-out form (“Opt-Out Form”) furnished by the applicable Provider: (a) the disclosure of my vaccination information by the applicable Provider to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from sharing my vaccination information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. The applicable Provider 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 the applicable Provider reporting my vaccination information to the Government Agencies, 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 the applicable Provider 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 the applicable Provider 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 or federal law may permit certain disclosures of my vaccination information to or through the State HIE or to Government Agencies as required or permitted by law. I further authorize the applicable Provider to: (a) release my medical or other information, including any communicable disease (including HIV) and mental health information, to, or through, the State HIE or Government Agencies 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 the applicable Provider with respect to the above requested items and services. I further agree to be fully financially responsible for any cost-sharing 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 the applicable Provider invoices me after the time of service, upon receipt of such invoice. Walgreens or its affiliates may contact you, including by autodialed and prerecorded calls and texts, at any time, using the contact information provided in your patient record regarding health and safety matters, such as vaccine reminders.

Patient signature:

Date:

(Parent or guardian, if minor)

©2021 Walgreen Co. All rights reserved. | 1604234-4463 | Rev. 4/22/21

SECTION DINSURANCEPATIENT OR AUTHORIZED PERSON TO COMPLETE

 

Please ensure to record BOTH pharmacy AND medical insurance information since there are multiple ways vaccinations can be billed at Walgreens.

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharmacy card

Medical card

 

 

Medicare

Medicare Part B

 

 

 

 

 

 

 

 

 

Medicare number:*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Plan/Plan ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last 4 digits of SSN:

 

 

 

 

 

 

 

 

 

 

Member/Recipient ID #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Number on the red, white and blue Medicare card.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

†For insurance confirmation purposes only.

 

 

 

 

 

 

 

RX BIN:

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RX PCN:

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COVID-19 VACCINATION ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group Number:

 

 

 

 

 

 

 

If uninsured: I attest that I do not have any medical or pharmacy insurance.

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you the cardholder?

Yes

No

 

Driver’s license/State ID number* (circle one)

 

Issuing state:

 

 

 

 

 

*For verification and coverage.

Initial here:

 

 

 

 

 

If no, please provide cardholder’s name,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Healthcare provider only: Individual refused to provide insurance information when

·

 

date of birth (MM/DD/YYY) and relationship:

 

I attempted to obtain the insurance information from the individual.

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

--------------------1. I

 

SECTION E

 

 

 

 

 

 

 

 

 

HEALTHCARE PROVIDER ONLY

 

 

 

 

 

 

 

Complete BEFORE vaccine administration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

have reviewed the Patient Information and Screening Questions.

 

 

 

Initial here:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. I have verified that this is the vaccine requested by the patient.

 

 

 

Initial here:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. This vaccine is appropriate for this patient based on the Age Guidelines provided by federal and/or state regulations

Initial here:

 

 

 

 

and company policies.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3a. Does this patient have a high-risk medical condition?

 

 

 

 

Yes

No

 

 

 

 

If yes, please list medical condition(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. I have discussed with the patient additional immunizations the patient may be eligible for based on age and/or health conditions.

Initial here:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. The Vaccine NDC matches the NDC on the bottom of this VAR form and the NDC on the patient leaflet.

Initial here:

 

 

 

 

(Perform 3-way NDC match.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

I have verified the Expiration Date is greater than today’s date and have entered the Lot # and Expiration Date in the field below.

Initial here:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

I have made every attempt to obtain and confirm patient insurance information.

 

 

 

Initial here:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For COVID-19, Shingrix®, MMR® II, Varivax®, YF-Vax®, Menveo®, Imovax®, Vaxchora® and RabAvert®, ensure the vaccine is reconstituted following -the package insert’s instructions.

SECTION F

Complete DURING the patient interaction

 

 

 

 

 

1.

I have asked the patient to confirm their Name, DOB and Requested Vaccine and verified it matches the information

Initial here:

 

 

on the VAR form.

 

 

 

 

 

 

 

2.

I have reviewed the Screening Questions with the patient.

Initial here:

 

 

 

 

 

-

 

 

3.

I have reviewed the VIS/Patient Fact Sheet with the patient.

Initial here:

 

 

 

 

 

SECTION G

Complete AFTER vaccine administration

Vaccine

NDC

Manufacturer

Dosage

Dose #

Site of

Vaccine

Vaccine

Diluent

Diluent

VIS/Patient

 

 

(if applicable)

Administration

Lot #

Expiration

Lot # (if

Expiration

Fact Sheet

 

 

 

 

 

 

applicable)

(if applicable)

Published

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

Clinician’s name (print):

 

 

Clinician signature:

 

 

Title:

 

If applicable, intern/tech name (print):

 

 

 

 

Administration date:

 

 

Date EUA Fact Sheet/VIS given to patient:

 

 

 

 

 

 

 

 

Notes

Reminder

1.Update the patient’s record with any new allergy, health condition or primary care provider information.

2.Enter vaccine lot #, expiration date and site of administration, then scan the VAR form into the patient’s record.

©2021 Walgreen Co. All rights reserved. | 1604234-4463 | Rev. 4/22/21

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walgreens administration vaccination fields to fill out

You need to submit the If, yes, please, list Yes, Yes, Yes, Yes Yes, Dont, know Yes, Yes NoNo, DontknowDont, know Yes, Dont, know Pneumonia, Date, received Shingles, Date, received Whooping, cough, Date, received in, the, past, year thymus, removed, yellow, fever, only and Yes, Yes, Yes box with the demanded particulars.

stage 2 to finishing walgreens administration vaccination

You need to point out the essential particulars in the Patient, signature Wal, green, Co, All, rights, reserved, Rev Parent, or, guardian, if, minor and Date field.

Filling in walgreens administration vaccination stage 3

The Medicare, Part, B Pharmacy, card, Medical, card Insurance, Plan, Plan, ID Member, Recipient, ID RXB, IN R, XP, CN Group, Number Issuing, state, Initial, here Yes, HEALTHCARE, PROVIDER, ONLY Initial, here, Initial, here, Initial, here If, yes, please, list, medical, conditions Perform, way, ND, C, match Yes, No and Initial, here, Initial, here space is where both parties can put their rights and obligations.

walgreens administration vaccination MedicarePartB, PharmacycardMedicalcard, InsurancePlanPlanID, MemberRecipientID, RXBIN, RXPCN, GroupNumber, IssuingstateInitialhere, Yes, HEALTHCAREPROVIDERONLY, InitialhereInitialhereInitialhere, Ifyespleaselistmedicalconditions, PerformwayNDCmatch, YesNo, and InitialhereInitialhere blanks to insert

Finalize by checking the next sections and filling in the proper information: Vaccine, on, the, VAR, form Initial, here InitialhereInitial, here ND, C Manufacturer, Dosage, Dose if, applicable Site, of, Administration Vaccine, Lot Vaccine, Expiration DiluentLotif, applicable DiluentExpirationif, applicable VIS, Patient, Fact, Sheet, Published, Date Clinician, signature and Title.

Filling out walgreens administration vaccination step 5

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