Vaccine Administration Record (Var) - Walgreens printable pdf download

Vaccine Administration Record (VAR) Informed Consent

†

for Vaccination for All Healthcare Providers*

PATIENT: COMPLETE SECTIONS A, B, C

SECTION A

Store Number:

Encounter ID:

(Please print clearly.)

Store Address:

First Name:

Last Name:

Date of Birth:

Age:

Gender:

Female

Male Home Phone:

Mobile Phone:

Race/Ethnicity (select one or more)

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):

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

Don’t Know

2. Have you ever fainted or felt dizzy when receiving an immunization?

Yes

Don’t Know

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

Yes

Don’t Know

4. Are you 19 years of age or older with an immunocompromising condition, functional or anatomic asplenia, CSF leak,

Yes

Don’t Know

or cochlear implant?

5. Do you have allergies to medications, food or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin,

Yes

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

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

Don’t Know

or other nervous system problems?

8. For women: Are you pregnant or considering becoming pregnant in the next month?

Yes

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

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

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

Don’t Know

past year?

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

Yes

Don’t Know

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

Yes

Don’t Know

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

Yes

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

Don’t Know

16. For patients 5 years of age and younger only: Is there a history of asthma or wheezing?

Yes

Don’t Know

17. Do you have a nasal condition serious enough to make breathing difficult, such as a very stuffy nose?

Yes

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 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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