**
IMMUNIZATION
LOCATION
Vaccine Administration Record (VAR) Informed Consent for Vaccination*
Section A Please print clearly.
Date of Birth Age Gender
Male
Home Phone
Female
First Name MI Last Name
Home Address City State ZIP Code
Email Address Medicare Part B Number (if applicable)
Primary Care Physician/Provider Name (if known) Physician/Provider Phone
Physician/Provider Address City State
Section B The following questions will help us determine your eligibility to be vaccinated today.
YES NO
DON’T
KNOW
ALL VACCINES
1. Which vaccines are you requesting to have administered today? Please check all requested vaccines:
Flu Shot Flu Nasal Spray (live — ages 2–49 only)
Flu HD (ages 65+) Pneumonia
Shingles Other
2. Do you feel sick today?
3. Do you have allergies to medications, food or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol or thimerosal)
If yes, please list the allergies:
4. Have you received any vaccinations or skin tests in the past four weeks? If yes, please list the vaccination.
5. Have you ever had a serious reaction to an influenza vaccine or any other vaccine in the past?
6. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré syndrome (a condition that causes paralysis) or
other nervous system problem?
7. Are you 65 years of age or older?
8. Do you smoke?
9. Do you have a chronic condition or long-term health problem? If yes, please check all that apply.
Anemia Asthma Diabetes Heart disease
Kidney disease Liver disease Lung disease
Other
10. If you answered YES to question #7, 8 or 9, have you ever had a pneumonia vaccination?
11.
Have you ever had a shingles vaccination (for patients 60 years of age and older only)?
12. Are you a healthcare worker?
13. For women: Are you pregnant or considering becoming pregnant in the next month?
LIVE VACCINES
14. Are you currently on home infusions, weekly injections, steroid therapy, anticancer drugs or radiation treatments?
15. Do you have cancer, leukemia, lymphoma, HIV/AIDS or any other immune system disorder or are you in contact with anyone who has a severely
weakened immune system?
16. Have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin in the past year?
17. Are you receiving aspirin therapy or aspirin-containing therapy? (18 years of age and younger only)
18. If the patient receiving vaccine is under 5 years old, is there a history of asthma or wheezing? (for FluMist
®
only)
19. Does the patient have a nasal condition serious enough to make breathing difficult, such as a very stuffy nose? (for FluMist
®
only)
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
SM
, 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
SM
, 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: I understand the purposes/benefits of my state’s immunization
registry (“State Registry”). I acknowledge that, depending upon my state law, I may prevent, by using a state-approved opt-out form (“Opt-Out Form”): (a) disclosure of my immunization information to the State Registry; or (b) the State Registry from
sharing my immunization information with any of my other healthcare providers enrolled in the State Registry. Walgreens or Take Care Health Services
SM
, as applicable, will, if my state permits, provide me with an Opt-Out Form. Unless I provide
Walgreens or Take Care Health Services
SM
, as applicable, with a signed Opt-Out Form, I elect to participate fully in, and consent to Walgreens or Take Care Health Services
SM
, as applicable, reporting my immunization information to the State Registry.
I authorize Walgreens or Take Care Health Services
SM
, as applicable, to (1) 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, (2) submit a claim to my insurer for the above requested items and services, and (3) request payment of authorized benefits be made on my behalf to
Walgreens or Take Care Health Services
SM
, 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, 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
SM
invoices me after the time of service, upon receipt of such invoice.
Patient Signature:
Date:
(Parent or Guardian, if minor)
Section D (HEALTH CARE PROVIDERS ONLY) The following section is to be completed by the health care provider only.
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: _________________
Vaccine Lot # Exp Date Manufacturer Dosage Circle Site of Injection VIS Date RPh Pre-fill Initials
Inactivated influenza -PF 0.5 ml L / R Deltoid IM
*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
SM
, 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
SM
, LLC.
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