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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. 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
