Question	Answer
Form Name	Walgreens Var Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	179
Avg. time to fill out	36 min 22 sec
Other names	walgreens vaccine consent form, walgreens var, walgreens informed consent for vaccination, walgreens vaccine form


	STORE NUMBER:	ENCOUNTER ID:
	STORE ADDRESS:
	Date of Birth:		Age:
Mobile Phone:

SECTION B		The following questions will help us determine your eligibility to be vaccinated today. For all vaccines: Please answer questions 1-8.
SECTION B		For live vaccines (e.g., MMR or Shingles): Please answer questions 1-14. For Flu nasal spray: Please answer questions 1-17.

All Vaccines
1.	Are you currently sick with a moderate to high fever, vomiting/diarrhea?		Yes	No	Don’t Know

2.	Have you ever fainted or felt dizzy when receiving an immunization?		Yes	No	Don’t Know

3.	Have you ever had a serious reaction after receiving an immunization?		Yes	No	Don’t Know

4.	Are you 19 years of age or older with an immunocompromising condition, functional or anatomic asplenia, CSF leak,		Yes	No	Don’t Know
	or cochlear implant?

5.	Do you have allergies to medications, food or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin,		Yes	No	Don’t Know
	neomycin, phenol, yeast or thimerosal)
	a. If yes, please list:

6.	Have you received any vaccinations or skin tests in the past four weeks?		Yes	No	Don’t Know
	a. If yes, please list:

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
	or other nervous system problems?

8.	FOR WOMEN: Are you pregnant or considering becoming pregnant in the next month?		Yes	No	Don’t Know
Live Vaccines (Chicken pox, Flu nasal spray, MMR, Oral typhoid, Shingles, Yellow fever)
Only answer these questions if you are receiving any immunization listed above
9.	Are you currently on home infusions, weekly injections (such as adalimumab, inﬂiximab and etanercept), high-dose		Yes	No	Don’t Know
	methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs or radiation treatments?

10.	Do you have cancer, leukemia, lymphoma, HIV/AIDS or any other immune system disorder?		Yes	No	Don’t Know

11.	Have you received a transfusion of blood or blood products or been given a medicine called immune (gamma) globulin in the		Yes	No	Don’t Know
	past year?

12.	Are you currently taking high-dose steroid therapy (prednisone >20mg/day) for longer than two weeks?		Yes	No	Don’t Know

13	Do you have a history of thymus disease (including myasthenia gravis), thymoma or prior thymectomy? (Yellow fever only)		Yes	No	Don’t Know

14.	Are you currently taking any antibiotics or antimalarial medications? (Oral typhoid only)		Yes	No	Don’t Know
Flu Nasal Spray (FluMist®)
15.	For patients 18 years of age and younger only: Are you receiving aspirin therapy or aspirin-containing therapy?		Yes	No	Don’t Know

16.	For patients 5 years of age and younger only: Is there a history of asthma or wheezing?		Yes	No	Don’t Know

17.	Do you have a nasal condition serious enough to make breathing difﬁcult, such as a very stuffy nose?		Yes	No	Don’t Know

SECTION D		HEALTHCARE PROVIDER ONLY
Complete BEFORE vaccine administration

Vaccine	Route	Dosage	Lot #	Expiration Date

Inﬂuenza (MDV)	Intramuscular	0.5mL
Inﬂuenza (Intradermal)	Intradermal	Preﬁlled

Inﬂuenza (Nasal)	Intranasal	0.1mL each nostril
Inﬂuenza (High dose)	Intramuscular	Preﬁlled

Chicken pox (Varicella)	Subcutaneous	0.5mL

Hepatitis A	Intramuscular	1mL: Adults ≥19 years
Hepatitis A	Intramuscular	0.5mL: Adolescents ≤ 18 years
		0.5mL: Adolescents ≤ 18 years
Hepatitis B	Intramuscular	1mL: Adults ≥20 years
Hepatitis B	Intramuscular	0.5mL: Adolescents ≤ 19 years
		0.5mL: Adolescents ≤ 19 years
Hepatitis A/B (Twinrix®)	Intramuscular	1mL: Adults ≥18 years
Human papillomavirus	Intramuscular	0.5mL
Japanese encephalitis	Subcutaneous	0.5mL
	Intramuscular
Meningococcal (Meningitis)	(Subcutaneous –	0.5mL
	Menomune Only)
MMR (Measles, Mumps, Rubella)	Subcutaneous	0.5mL
Pneumococcal (Pneumonia)	Intramuscular	0.5mL

Polio	Intramuscular	0.5mL
Shingles (Herpes Zoster)	Subcutaneous	0.65mL
Td (Tetanus and diphtheria)	Intramuscular	0.5mL
Tdap (Tetanus, diphtheria	Intramuscular	0.5mL
and pertussis)	Intramuscular	0.5mL
and pertussis)
Typhoid (Live Oral)	Orally
Typhoid (Inactive injectable)	Intramuscular	0.5mL
Yellow fever	Subcutaneous	0.5mL

Needle size		Age
Intramuscular injection is in the deltoid

I have veriﬁed the immunization(s) that the patient requested meets state, age and vaccine restrictions.	Initial here:

I have veriﬁed the requested immunization(s) is the same as the product prepared.	Initial here:

I have veriﬁed the expiration date of the product is greater than today’s date.	Initial here:

For Zostavax®, MMR II®, Varivax®, YF-Vax®, Menveo®, I have reconstituted the vaccine following the package insert’s instructions.	Initial here:

Did you verify if a second dose is needed?	Yes	No
If this is the second dose, have 28 days elapsed since the ﬁrst dose?	Yes	No

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:

Notes

First Name:				Last Name:
Gender: Female		Male Home Phone:

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