Vaccine Administration Record (Var) - Informed Consent For Vaccination - Influenza(Flu) Vaccine Page 2
ADVERTISEMENT
1
2Patient name:
SECTION D
HEALTHCARE PROVIDER ONLY
Complete BEFORE vaccine administration
1. I have reviewed the Patient Information and Screening Questions.
Initial here:
2. This is the Vaccine Requested by the patient.
Initial here:
3. This vaccine is appropriate for this patient based on the Age Guidelines provided by federal, state regulations and company policies.
Initial here:
3a. Does this patient have a high-risk medical condition?
Yes
No
If yes, please list medical condition(s):
4. The Vaccine NDC Matches the NDC on the bottom of this VAR form and the NDC on the patient leaflet. (Perform 3-way NDC match).
Initial here:
5. I have verified the Expiration Date is greater than today’s date and have entered the Lot # and Expiration Date in the field below.
Initial here:
Lot #:
Expiration Date:
Note: For Zostavax
, MMR
II, Varivax
, YF-Vax
, Menveo
, Imovax
and Rabavert
, ensure the vaccine is reconstituted following the package insert’s instructions.
®
®
®
®
®
®
®
SECTION E
Complete DURING the Patient Interaction
1. I have asked the patient to confirm their Name, DOB and Requested Vaccine and verified it matches the information on the VAR form.
Initial here:
2. I have reviewed the Screening Questions with the patient.
Initial here:
3. I have reviewed the VIS with the patient.
Initial here:
SECTION F
Complete AFTER vaccine administration
Vaccine
NDC
Manufacturer
Dosage
Site of administration
VIS published date
Immunizer name (print):
Immunizer signature:
Title:
If applicable, intern name (print):
Administration date:
Date VIS given to patient:
Notes
Reminder:
1. Update the patient’s record with any new allergy, health condition or primary care provider information.
2. Enter vaccine lot #, expiration date and site of administration, then scan the VAR form into the patient’s record.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal