Walgreens Questionnaire PDF Details

Walgreens recently introduced a new questionnaire form that customers are required to fill out in order to receive store credit. This form is an important part of the Walgreens return policy, and it is crucial that customers understand why the form is being used and what information is being collected. The following blog post will provide an overview of the Walgreens questionnaire form, including information on why it was created and what it covers.

Below is the information in regards to the PDF you were in search of to fill out. It will show you the time it will need to finish walgreens questionnaire, exactly what fields you will need to fill in, and so on.

QuestionAnswer
Form NameWalgreens Questionnaire
Form Length2 pages
Fillable?Yes
Fillable fields99
Avg. time to fill out20 min 22 sec
Other nameswalgreens supplier net, supplier net walgreens, supplier net, walgreens supplier portal

Form Preview Example

Appt. Date:____/____/____ Appt. Time: _ : _ AM/PM

PRE-TRAVEL QUESTIONNAIRE FORM

(Please Print Clearly)

This form is to be completed to obtain patient, vaccine and destination-specific information for the Travel Health Consultation.

SECTION A — TRAVELER INFORMATION

First Name:___________________________________ Last Name:___________________________________________________

Date of Birth:____/____/____ Age:______ Gender:

M

F Email:_______________________________________________

Home Address:__________________________________________________________Primary Phone: (_____)________________

City:__________________________________________________________________ State:_______ ZIP Code:_______________

Doctor/Primary Care Provider:__________________________________________ Provider Phone: (_____)_________________

Provider Address:_______________________________ City:__________________ State:_______ ZIP Code:________________

Provider Email:_______________________________________________

I do not have a doctor/primary care provider.

SECTION B — MEDICAL HISTORY

Allergies and Health Conditions

List all chronic health problems, illnesses or allergies: (e.g. heart disease, high blood pressure, diabetes, etc.)

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Medications

List all current medications you are taking: (prescription, over-the-counter, herbals and vitamins)

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Women only: Are you pregnant, trying to become pregnant or nursing?

Yes

No

SECTION C — IMMUNIZATION HISTORY: Which immunizations have you had in the past?

Vaccines

Yes/No

Date (If known)

Vaccines

Yes/No

Date (If known)

Influenza (Flu)

 

 

Typhoid (Oral or Injectable)

 

 

 

 

 

 

 

 

Tetanus/Diphtheria/Pertussis

 

 

Meningococcal

 

 

 

 

 

 

 

 

Measles/Mumps/Rubella

 

 

Hepatitis A

 

 

 

 

 

 

 

 

Pneumonia

 

 

Hepatitis B

 

 

 

 

 

 

 

 

Varicella (Chicken Pox)

 

 

Polio

 

 

 

 

 

 

 

 

Japanese Encephalitis

 

 

HPV

 

 

 

 

 

 

 

 

Rabies

 

 

Shingles

 

 

 

 

 

 

 

 

Yellow Fever

 

 

Other:

 

 

 

 

 

 

 

 

Page 1

SECTION D — TRAVEL ITINERARY: Where are you going?

Departure Date:______/______/______

Return Date:______/______/______

 

 

 

 

 

Countries To Be Visited (In Order)

 

City or Region

Length of Stay (Days)

1.

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

Accommodations:

Hotel/Hostel

Private Home

Cruise

Camping

Other______________________________

Do you plan to visit rural areas (areas with animal/insect/mosquito-borne disease risk)?

Yes

No

 

Do you plan to travel or to climb to high altitudes (more than 4,000 feet)?

Yes

No

 

 

 

Do you plan to go swimming? Yes

No If yes, where? Chlorinated Pool

Fresh Water Lake or Stream

Ocean

Do you suffer from motion sickness?

Yes No Do you anticipate getting motion sickness on this trip? Yes

No

List any additional information on travel-related topics you would like to discuss:____________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Do you need a passport picture? Yes No

SECTION E — PATIENT CONSENT

I acknowledge that I am the (1) above Traveler and an adult or (2) parent or legal guardian of the above minor Traveler and have requested a Travel Consultation (“Travel Consult”) for the Traveler from Walgreens, which is intended to provide general information relevant to the above travel plans to the identified country(ies). I understand and agree that:

The Travel Consult (i) may not provide an exhaustive list of all risks associated with, or conditions to, the above travel plans; (ii) does not constitute medical advice and is not being conducted for diagnostic or treatment purposes; and (iii) may not be covered by insurance. Further, Walgreens may not be able to submit a claim to an insurer for the Travel Consult on behalf of the Traveler; and

I agree to full financial responsibility for the Travel Consult and understand that payment for such service is due upon receipt. I understand that Walgreens price for the Travel Consult does not include the cost for any (i) immunizations or prescriptions that I may request at Walgreens pharmacy or (ii) any over-the­ counter travel-related products that I may purchase at Walgreens.

Patient Printed Name:_________________________________________________________________________________________________

Patient Signature_____________________________________________________________________________ Date:______/______/______

Page 2

How to Edit Walgreens Questionnaire Online for Free

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Step 2: Now you are allowed to manage vendor walgreens com. You have a wide range of options with our multifunctional toolbar - you can include, eliminate, or alter the information, highlight the particular sections, as well as conduct many other commands.

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walgreens vendor blanks to consider

Within the box Medications, Yes, No Vaccines, Influenza, Flu Tetanus, Diphtheria, Pertussis Measles, Mumps, Rubella Pneumonia, Varicella, ChickenPox Japanese, Encephalitis Rabies, Yellow, Fever Yes, No, Date, If, known Vaccines, Typhoid, Oral, or, Inject, able Yes, No, Date, If, known Men, in, go, co, c, cal and Hepatitis, A type in the data the application requests you to do.

stage 2 to entering details in walgreens vendor

The application will require for further details in order to easily fill in the section Departure, Date Return, Date Countries, To, Be, Visited, In, Order City, or, Region Length, of, Stay, Days Accommodations, Hotel, Hostel Private, Home Cruise, Camping, Other, Yes, No Yes, No Do, you, plan, togo, swimming and Yes, No, If, yes, where, Chlorinated, Pool

walgreens vendor DepartureDate, ReturnDate, CountriesToBeVisitedInOrder, CityorRegion, LengthofStayDays, Accommodations, HotelHostel, PrivateHome, Cruise, Camping, Other, YesNo, YesNo, Doyouplantogoswimming, and YesNoIfyeswhereChlorinatedPool fields to fill out

Identify the rights and responsibilities of the parties within the space Patient, Printed, Name and Patient, Signature, Date

Filling in walgreens vendor part 4

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