Vaccine Administration Record

Vaccine Administration Record (VAR) Informed Consent

†

for Vaccination for all healthcare providers*

PATIENT: COMPLETE SECTIONS A, B, C

PROVIDER: COMPLETE SECTION D (reverse side)

SECTION A

(Please print clearly.)

First name:

Last name:

Date of birth:

Age:

Gender:

Female

Male Home phone:

Mobile phone:

Race (select one or more)

Ethnicity (select one)

Native American or Alaska Native

Asian

Black or African-American

Native Hawaiian or other Pacific Islander

White

Other

Hispanic or Latino

Not Hispanic or Latino

Home address:

City:

State:

ZIP code:

Email address:

Doctor/primary care provider name:

Phone number:

Address:

City:

State:

I do not have a primary care doctor/provider

I want to receive the following immunization(s):

Flu (influenza)

Pneumonia (pneumococcal)

Shingles (herpes zoster)

Tdap (whooping cough)

Other:

The following questions will help us determine your eligibility to be vaccinated today. For all vaccines: Please answer questions 1-7.

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 after receiving an immunization?

Yes

No

Don’t know

3. Have you ever had a reaction after receiving an immunization?

Yes

No

Don’t know

4. Do you have an immunocompromising condition (e.g., cancer, leukemia, lymphoma, HIV/AIDS, transplant), functional,

Yes

No

Don’t know

or anatomic asplenia, CSF leak or cochlear implant?

5. Do you have allergies to latex, 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 ever had a seizure disorder for which you are on seizure medications, a brain disorder, Guillain-Barré syndrome or

Yes

No

Don’t know

other nervous system problems?

7. 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.

8. 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?

9. Have you received any vaccinations or skin tests in the past four weeks?

Yes

No

Don’t know

a. If yes, please list:

10. Have you received a transfusion of blood, blood products or been given a medication called immune (gamma) globulin

Yes

No

Don’t know

in the past year?

11. Are you currently taking high-dose steroid therapy (prednisone >20mg/day or equivalent) for longer than two weeks?

Yes

No

Don’t know

12 Do you have a history of thymus disease (including myasthenia gravis), thymoma or prior thymectomy? (Yellow fever only)

Yes

No

Don’t know

13. Are you currently taking any antibiotics or antimalarial medications? (Oral typhoid only)

Yes

No

Don’t know

14. Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only)

Yes

No

Don’t know

Flu nasal spray (FluMist

Quadrivalent)

®

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: (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 or Take Care Health Services

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, 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 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 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

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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) Walgreens or Take Care Health Services

, as applicable, 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

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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, a

Walgreens or Take Care Health Services

opt-out form (“Opt-Out Form”): (a) the disclosure of my immunization information by Walgreens or Take Care Health Services

to the State HIE and/or State Registry; or (b) the State HIE and/or State Registry from

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sharing my immunization information with any of my other healthcare providers enrolled in the State Registry and/or State HIE. Walgreens or Take Care Health Services

, as applicable, will, if my state permits, provide me with an Opt-Out Form. I understand

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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 Walgreens or Take Care Health Services

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, as applicable, 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 Walgreens or Take Care Health Services

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, as applicable, 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 Walgreens, Take Care Health Services

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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 Walgreens or Take Care Health Services

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, as applicable, 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 Walgreens or Take Care Health Services

, as applicable, to (a) release my medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information, to, or

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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 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 cosharing amounts, including copays,

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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.

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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, physician or physicians assistant.

†

Patient care services at Healthcare Clinic at select Walgreens 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. Walgreen Co. and its subsidiary companies provide management services to provider practices, in-store clinics and worksite health and wellness centers.

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