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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.
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) l