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Vaccine Administration Record (VAR)—Informed Consent for Vaccination
Store number:
Rx number:
Store address:
Please print clearly.
First name: Last name:
Date of birth: Age: Gender: Female Male Phone:
I wish to receive text message alerts regarding my prescriptions.
Home address: City:
State: ZIP code: Email address:
SECTION A
Race: American Indian or Alaska Native Asian Native Hawaiian or Other Pacic Islander Black or African American White
Other Race Unknown
Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown ethnicity
Walgreens will send vaccination information from this visit to your doctor/primary care provider using the contact information provided below.
Doctor/primary care provider name: Phone:
Address: City: State: ZIP code:
I want to receive the following vaccination(s):
SECTION B
The following questions will help us determine your eligibility to be vaccinated today.
All vaccines
1. Do you feel sick today? Yes No Don’t know
2. Have you been diagnosed with or tested positive for COVID-19 in the last 14 days? Yes No Don’t know
3. In the past 14 days have you been identied as a close contact to someone with COVID-19? Yes No Don’t know
4. Do you have a history of allergic reaction or allergies to latex, medications, food or vaccines (examples: polyethylene glycol, Yes No Don’t know
polysorbate, eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)?
If yes, please list:
5. Have you ever had a reaction after receiving a vaccination, including fainting or feeling dizzy? Yes No Don’t know
6. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré syndrome Yes No Don’t know
(a condition that causes paralysis) or other nervous system problem?
7. Have you received any vaccinations or skin tests in the past eight weeks? Yes No Don’t know
If yes, please list:
8. Have you ever received the following vaccinations?
Pneumonia: Date received Shingles: Date received Whooping cough: Date received
9. Do you have any chronic health condition such as cancer, chronic kidney disease, immunocompromised, chronic lung disease, Yes No Don’t know
obesity, sickle cell disease, diabetes, heart disease?
If yes, please list:
10. For women: Are you pregnant or considering becoming pregnant in the next month? Yes No Don’t know
11. For COVID-19 vaccine only: Have you been treated with antibody therapy specically for COVID-19 (monoclonal antibodies Yes No Don’t know
or convalescent plasma)?
For chickenpox, MMR
®
II, shingles, Vaxchora
®
, yellow fever only:
Answer the following questions only if you are receiving any vaccinations listed above.
12. Do you have a condition that may weaken your immune system (e.g., cancer, leukemia, lymphoma, HIV/AIDS, transplant)? Yes No Don’t know
13. Are you currently on home infusions, weekly injections such as Humira
®
(adalimumab), Remicade
®
(iniximab) or Enbrel
®
Yes No Don’t know
(etanercept), high-dose methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs or radiation treatments?
14. Are you currently taking high-dose steroid therapy (prednisone > 20mg/day or equivalent) for longer than 2 weeks? Yes No Don’t know
15. Have you received a transfusion of blood or blood products or been given a medication called immune (gamma) globulin Yes No Don’t know
in the past year?
16. Do you have a history of thymus disease (including myasthenia gravis, DiGeorge syndrome or thymoma), or had your Yes No Don’t know
thymus removed? (yellow fever only)
17. Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only) Yes No Don’t know
18. Have you consumed any food or drink in the last hour? (Vaxchora
®
only) Yes No Don’t know
19. Have you taken antibiotics in the last 14 days or antimalarials in the last 10 days? (Vaxchora
®
only) Yes No Don’t know
SECTION C
I certify that I am: (a) the patient and at least 18 years of age; (b) the legal guardian of the patient; or (c) a person authorized to consent on behalf of the patient where the patient is not otherwise competent or unable to consent
for themselves. Further, I hereby give my consent to Walgreens or Duane Reade and the licensed healthcare professional administering the vaccine, 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 benets associated with the above vaccine(s) and
have received, read and/or had explained to me the EUA Fact Sheet 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 that the patient should remain near the vaccination location for observation for approximately 15 minutes after administration. On behalf of the patient, the patient’s
heirs and personal representatives, I hereby release and hold harmless each applicable Provider, its staff, agents, successors, divisions, afliates, subsidiaries, ofcers, 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/benets of my state’s
vaccination registry (“State Registry”) and my state’s health information exchange (“State HIE”); and (b) the applicable Provider may disclose my vaccination information to the State Registry, to the State HIE, or through the
State HIE to the State Registry, or to any state or federal governmental agencies or authorities (“Government Agencies”), such as state, county, or local Departments of Health or the federal Department of Health and Human
Services, the Centers for Disease Control and Prevention, or their respective designees as may be required by law, for purposes of public health reporting, or to my healthcare 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 vaccination 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 vaccination 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 specically consent, and, to the extent required by my state’s law, by signing below, I hereby do consent to the applicable Provider reporting my vaccination information to the Government Agencies, 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 or federal law may permit certain disclosures of my vaccination information to or through the State HIE or to Government Agencies as required or permitted by law. I further
authorize the applicable Provider to: (a) release my medical or other information, including any communicable disease (including HIV) and mental health information, to, or through, the State HIE or Government Agencies 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 benets be made on my behalf to the applicable Provider with respect to the above requested items and services. I further agree to be fully nancially 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 benets. I understand that any payment for which I am nancially responsible
is due at the time of service or, if the applicable Provider invoices me after the time of service, upon receipt of such invoice. Walgreens or its afliates may contact you, including by autodialed and prerecorded calls and texts,
at any time, using the contact information provided in your patient record regarding health and safety matters, such as vaccine reminders.
Patient signature: Date:
(Parent or guardian, if minor)
©2021 Walgreen Co. All rights reserved. | 1570176-1631 | Rev. 022321
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