Walgreens Vaccination Consent Form Details

Last month, Walgreens announced a new initiative to offer their customers more convenience and choice when it comes to filling their prescriptions. This new program, called Walgreens Var Form, offers patients the option to pick up medications in either the traditional pill form or in a liquid concentrate. While some patients may prefer the traditional pill form, others may find that the liquid concentrate is a more convenient option. In addition, for certain medications, the liquid concentrate may be a more cost-effective option. For example, if you are taking a medication that needs to be administered through an IV drip, it may be cheaper to purchase the medication in liquid concentrate form than to buy it in pill form.

Here is the details in regards to the file you were seeking to fill in. It will show you the time it takes to complete walgreens var form, what parts you need to fill in, etc.

QuestionAnswer
Form NameWalgreens Var Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesvar form, walgreens informed consent vaccination form, vaccine administration record var informed consent for vaccination, vaccination consent form walgreens

Form Preview Example

Vaccine Administration Record (VAR) Informed Consent for Vaccination for All Healthcare Providers*

PATIENT: COMPLETE SECTIONS A, B, C

SECTION A (Please print clearly.)

First Name:

 

 

 

Last Name:

Gender: Female

Male Home Phone:

 

Race/Ethnicity (select one or more)

 

STORE NUMBER:

 

 

 

ENCOUNTER ID:

 

 

 

 

STORE ADDRESS:

 

 

 

 

 

 

 

 

Date of Birth:

 

 

Age:

 

Mobile Phone:

 

 

 

 

 

 

 

 

 

Native American or Alaska Native

Asian

Black or African-American

White

Hispanic or Latino

 

Native Hawaiian or other Pacific Islander

Other

Home Address:

 

 

 

 

 

 

City:

 

 

 

 

 

State:

 

 

 

ZIP Code:

 

Email Address:

 

 

 

 

 

 

Medicare Part B Number (if applicable):

 

 

 

Primary Care Physician/Provider Name:

 

 

 

 

 

 

 

 

Phone Number:

 

 

Address:

 

 

 

City:

 

 

 

 

 

State:

 

 

I do not have a Primary Care Physician/Provider

I want to receive the following immunization(s):

SECTION B

The following questions will help us determine your eligibility to be vaccinated today. For all vaccines: Please answer questions 1-8.

 

 

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 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 Services, 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/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 Services, 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: (a) I understand the purposes/benefits of my state’s immunization registry (“Registry”); (b) I may, if my state permits, object to Walgreens disclosing my immunization information to the Registry by providing Walgreens with a state approved Registry disclosure opt out form (which I may request and obtain from Walgreens, if permitted by my state); and (c) Unless I provide Walgreens with an approved opt out form, I have elected to participate in the Registry and consented to Walgreens reporting

my immunization information. I authorize Walgreens or Take Care Health Services, as applicable, to (i) 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, (ii) submit a claim to my insurer for the above requested items and services, and (iii) request payment of authorized benefits be made on my behalf to Walgreens or Take Care Health Services, as applicable, with respect to the above requested items and services. I further agree to be fully financially responsible for any co-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 Walgreens or Take Care Health Services invoices me after the time of service, upon receipt of such invoice.

Signature:

 

Date:

(Parent or Guardian, if minor)

*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.

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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

 

 

0.5mL: Adolescents ≤ 18 years

 

 

 

 

 

 

 

 

Hepatitis B

Intramuscular

1mL: Adults ≥20 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)

 

 

 

 

 

 

Typhoid (Live Oral)

Orally

 

 

 

Typhoid (Inactive injectable)

Intramuscular

0.5mL

 

 

Yellow fever

Subcutaneous

0.5mL

 

 

 

 

 

 

 

Needle size

 

Age

 

 

Intramuscular injection is in the deltoid

 

 

 

to 1¼ inch needle

1 to 1½ inch needle

1½ inch needle

3-18 y/o ( inch needle for patients weighing less than 130 lbs)

19 y/o and older (Female 130-200 lbs; Male 130-260 lbs)

19 y/o and older (Female 200+ lbs; Male 260+ lbs)

Subcutaneous injection is in the upper arm (postero-lateral)

inch needle

All ages

Intradermal injection is in the deltoid

Prefilled Syringe

All ages

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:

 

For patients younger than 9 years of age requesting the influenza vaccine:

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

Complete AFTER vaccine administration

Rx #

Vaccine

NDC

Dosage

Site of Injection (circle site)

VIS Published Date

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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