Vaccine Administration Record (Var) - Informed Consent For Vaccination - Influenza(Flu) Vaccine


Vaccine Administration Record (VAR)–
Informed Consent for Vaccination*
Store number:
Rx number:
Store address:
(Please print clearly.)
First name:
Last name:
Date of birth:
Male Phone:
Home address:
ZIP code:
Email address:
Walgreens will send immunization information from this visit to your doctor/primary care provider using the contact information provided below.
Doctor/primary care provider name:
Phone number:
I want to receive the following immunization:
The following questions will help us determine your eligibility to be vaccinated today.
All vaccines
1. Do you feel sick today?
Don’t know
2. Do you have any health conditions such as: heart disease, diabetes or asthma?
Don’t know
If yes, please list:
3. Do you have allergies to latex, medications, food or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin,
Don’t know
neomycin, phenol, yeast or thimerosal)?
If yes, please list:
4. Have you ever had a reaction after receiving an immunization, including fainting or feeling dizzy?
Don’t know
5. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré Syndrome
Don’t know
(a condition that causes paralysis) or other nervous system problem?
6. For women: Are you pregnant or considering becoming pregnant in the next month?
Don’t know
I certify that I am: (a) the patient and at least 18 years of age; (b) the parent or legal guardian of the minor patient; or (c) the legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of Walgreens, Duane Reade, Take Care Health
Services, or DR Walk-in Medical Care, as applicable (each an “applicable Provider”), 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 the applicable Provider, 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 (“State
Registry”) and my state’s health information exchange (“State HIE”); and (b) the applicable Provider may disclose my immunization information to the State Registry, to the State HIE, or through the State HIE, to the State Registry, for purposes of public health
reporting or to my health care providers enrolled in the State Registry and/or State HIE for purposes of care coordination. I acknowledge that, depending upon my state’s law, I may prevent, by using a state-approved opt-out form or, as permitted by my state law,
an opt-out form (“Opt-Out Form”) furnished by the applicable Provider: (a) the disclosure of my immunization information by the applicable Provider to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from sharing my immunization
information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. The applicable Provider will, if my state permits, provide me with an Opt-Out Form. I understand that, depending on my state’s law, I may need to specifically
consent, and to the extent required by my state’s law, by signing below, I hereby do consent to the applicable Provider reporting my immunization information to the State HIE, or through the State HIE and/or State Registry to the entities and for the purposes
described in this Informed Consent form. Unless I provide the applicable Provider with a signed Opt-Out Form, I understand that my consent will remain in effect until I withdraw my permission and that I may withdraw my consent by providing a completed
Opt-Out Form to the applicable Provider and/or my State HIE, as applicable. I understand that even if I do not consent or if I withdraw my consent, my state’s laws may permit certain disclosures of my immunization information to or through the State HIE
as required or permitted by law. I also authorize the applicable Provider to disclose my, or my child’s (or unemancipated minor for whom I am authorized to act as guardian or in loco parentis) proof of immunization to the school where I am, or my child (or
unemancipated minor for whom I am authorized to act as guardian or in loco parentis) is, a student or prospective student. I further authorize the applicable Provider to (a) release my medical or other information, including my communicable disease (including
HIV), mental health and drug/alcohol abuse information, to, or through, the State HIE to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment, (b) submit a claim to my insurer for the above
requested items and services, and (c) request payment of authorized benefits be made on my behalf to the applicable Provider with respect to the above requested items and services. I further agree to be fully financially responsible for any cost 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, the applicable Provider invoices me after the time of service, upon receipt of such invoice.
Patient signature:
(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, physician or physicians assistant.
Patient care services at Walgreens Healthcare Clinic provided by Take Care Health Services, 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 Systems, LLC.


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