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.
Question | Answer |
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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* |
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IMMUNIZATION |
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LOCATION |
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SECTION A |
Please print clearly. |
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Home Phone |
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Date of Birth |
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Age |
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Gender |
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Male |
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Female |
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First Name |
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MI |
Last Name |
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Home Address |
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City |
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State |
ZIP Code |
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Email Address |
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Medicare Part B Number (if applicable) |
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Primary Care Physician/Provider Name (if known) |
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Physician/Provider Phone |
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Physician/Provider Address |
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City |
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State |
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SECTION B The following questions will help us determine your eligibility to be vaccinated today. |
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YES |
NO |
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DON’T |
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KNOW |
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1. Which vaccines are you requesting to have administered today? Please check all requested vaccines: |
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Flu Shot |
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Flu Nasal Spray (live — ages |
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Flu HD (ages 65+) |
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Pneumonia |
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Shingles |
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Other |
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2. Do you feel sick today? |
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3. Do you have allergies to medications, food or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol or thimerosal) |
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If yes, please list the allergies: |
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4. Have you received any vaccinations or skin tests in the past four weeks? If yes, please list the vaccination. |
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VACCINES |
5. Have you ever had a serious reaction to an influenza vaccine or any other vaccine in the past? |
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6. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, |
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other nervous system problem? |
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7. Are you 65 years of age or older? |
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ALL |
8. Do you smoke? |
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9. Do you have a chronic condition or |
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Other |
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Anemia |
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Asthma |
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Diabetes |
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Heart disease |
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Kidney disease |
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Liver disease |
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Lung disease |
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10. If you answered YES to question #7, 8 or 9, have you ever had a pneumonia vaccination? |
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11. Have you ever had a shingles vaccination (for patients 60 years of age and older only)? |
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12. Are you a healthcare worker? |
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13. For women: Are you pregnant or considering becoming pregnant in the next month? |
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14. Are you currently on home infusions, weekly injections, steroid therapy, anticancer drugs or radiation treatments? |
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VACCINES |
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17. Are you receiving aspirin therapy or |
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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 |
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weakened immune system? |
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16. Have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin in the past year? |
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LIVE |
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18. If the patient receiving vaccine is under 5 years old, is there a history of asthma or wheezing? (for FluMist® only) |
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19. Does the patient have a nasal condition serious enough to make breathing difficult, such as a very stuffy nose? (for FluMist® only) |
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SECTION C |
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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
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
Patient Signature: |
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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) |
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If applicable, Intern Name (print): _________________________________ Administration Date: ______________________ Date VIS given to Patient: _________________ |
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Vaccine |
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Lot # |
Exp Date |
Manufacturer |
Dosage |
Circle Site of Injection |
VIS Date |
RPh |
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Inactivated inluenza |
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0.5 ml |
L / R Deltoid IM |
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*Healthcare providers can be an |
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**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 |
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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 |