Community Off-Site Vaccine Administration Record (VAR)—Informed Consent for Vaccination*
* Healthcare providers can be a vaccination-certified pharmacist or a registered nurse, licensed practical nurse, licensed vocational nurse, nurse practitioner, physician or physician assistant.
Patient care services at Walgreens Healthcare Clinic 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.
SECTION A Please print clearly.
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, Duane Reade or Take Care
Health Services, 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 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 the applicable Provider, 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 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, 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 specifically 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 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 may permit certain disclosures of my vaccination information to or through the State HIE as required or permitted by law. I also authorize
the applicable Provider 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 vaccination 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 the applicable Provider to: (a) release my medical or other information, including my communicable disease (including HIV), mental health and drug/alcohol abuse information,
to, or 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 the applicable Provider with respect to the above requested items and services. I further agree to be fully financially 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 benefits. I understand that any payment for which I am financially 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.
Patient signature:
Date:
(Parent or guardian, if minor)
I want to receive the following vaccination(s):
First name:
Last name:
Date of birth:
Age:
Gender:
Female
Male Phone:
Home address:
City:
State:
ZIP code:
Email address:
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:

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. Do you have any health conditions, such as heart disease, diabetes or asthma?
If yes, please list:
Yes
No
Don’t know
3. Do you have allergies to latex, medications, food or vaccines (examples: eggs, bovine protein, gelatin, gentamicin, polymyxin,
neomycin, phenol, yeast or thimerosal)?
If yes, please list:
Yes
No
Don’t know
4. Have you ever had a reaction after receiving a vaccination, including fainting or feeling dizzy?
Yes
No
Don’t know
5. 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?
Yes
No
Don’t know
6. For women: Are you pregnant or considering becoming pregnant in the next month?
Yes
No
Don’t know
For chickenpox, MMR® II, shingles, yellow fever only:
Only answer these questions if you are receiving any vaccinations listed above.
7. Have you received any vaccinations or skin tests in the past four to eight weeks?
If yes, please list:
Yes
No
Don’t know
8. Do you have a condition that may weaken your immune system (e.g., cancer, leukemia, lymphoma, HIV/AIDS, transplant)?
Yes
No
Don’t know
9. Are you currently on home infusions, weekly injections such as Humira® (adalimumab), Remicade® (infliximab) or Enbrel®
(etanercept), high-dose methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs or radiation treatments?
Yes
No
Don’t know
10. Are you currently taking high-dose steroid therapy (prednisone > 20mg/day or equivalent) for longer than 2 weeks?
Yes
No
Don’t know
11. Have you received a transfusion of blood or blood products or been given a medication called immune (gamma) globulin in the
past year?
Yes
No
Don’t know
12. Do you have a history of thymus disease (including myasthenia gravis, DiGeorge syndrome or thymoma), or had your thymus
removed? (yellow fever only)
Yes
No
Don’t know
13. Do you have a history of thrombocytopenia or thrombocytopenia purpura? (MMR® II only)
Yes
No
Don’t know
SECTION B
OFF-SITE CLINIC BILLING GROUP:
Store number:
Store address:
Rx number:
©2018 Walgreen Co. All rights reserved. | 849610-9650
5806
3917 N NEBRASKA AVE,
TAMPA, FL 33603
Clinician’s name (print):
Clinician’s signature:
Title:
If applicable, intern name (print):
Administration date:
Date VIS given to patient:
SECTION D
SECTION F
HEALTHCARE PROVIDER ONLY
Complete BEFORE vaccine administration
Complete AFTER vaccine administration
Vaccine
NDC
Manufacturer
Dosage
Site of administration
VIS published date
1.
I have reviewed the Patient Information and Screening Questions.
Initial here:
2.
I have verified that 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 and/or state regulations
and company policies.
Initial here:
3a. Does this patient have a high-risk medical condition?
If yes, please list medical condition(s):
Yes
No
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:
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:
Lot #:
Expiration Date:
Lot #:
Expiration Date:
For Shingrix®, Zostavax®, MMR® II, Varivax®, YF-Vax®, Menveo®, Imovax® and RabAvert®, ensure the vaccine is reconstituted following the package insert’s instructions.
For vaccines that have a diluent, complete the following:
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.
Vaccine
Route
Dosage
Infl uenza
Intramuscular
0.5 mL
Infl uenza (intradermal)
Intradermal
0.1 mL
Infl uenza (nasal)
Intranasal
0.1 mL each nostril
Hepatitis A
Intramuscular
0.5 mL: Adolescents ≤ 18 years
1 mL: Adults ≥19 years
Hepatitis B
Intramuscular
0.5 mL: Adolescents ≤ 19 years
1 mL: Adults ≥20 years
Hepatitis B (Heplisav-B)
Intramuscular
0.5 mL
Hepatitis A/B (Twinrix)
Intramuscular
1 mL: Adults ≥18 years
Human papillomavirus
Intramuscular
0.5 mL
Japanese encephalitis
Intramuscular
0.5 mL
Meningococcal ACYW-135
Intramuscular
0.5 mL
Meningococcal B
Intramuscular
0.5 mL
MMR (measles, mumps, rubella)
Subcutaneous
0.5 mL
Pneumococcal (Prevnar 13)
Intramuscular
0.5 mL
Pneumococcal (Pneumovax 23)
Intramuscular or subcutaneous
0.5 mL
Polio
Intramuscular or subcutaneous
0.5 mL
Rabies
Intramuscular
1 mL
Shingles/herpes zoster (Zostavax)
Subcutaneous
0.65 mL
Shingles/herpes zoster (Shingrix)
Intramuscular
0.5 mL
Td (tetanus and diphtheria)
Intramuscular
0.5 mL
Tdap (tetanus, diphtheria and pertussis)
Intramuscular
0.5 mL
Typhoid
Intramuscular
0.5 mL
Varicella/chickenpox
Subcutaneous
0.5 mL
Yellow fever
Subcutaneous
0.5 mL
Vaccine Reference Chart
Notes
Reminder
©2018 Walgreen Co. All rights reserved. | 849610-9650