Walgreens Var Form ≡ Fill Out Printable PDF Forms Online

Question	Answer
Form Name	Walgreens Var Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	var form, walgreens informed consent vaccination form, vaccine administration record var informed consent for vaccination, vaccination consent form walgreens

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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.
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 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.

13FL0002

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

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

13FL0002

Walgreens Var Form – Fill Out and Use

Walgreens Vaccination Consent Form Details

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