All Health Care Providers

Vaccine Administration Record (VAR) | Informed Consent for Vaccination for All Health Care Providers*

PATIENT: COMPLETE SECTIONS: A, B, C

Name*

First NameLast Name

D.O.B*

MonthDayYear

Age:*

Gender:*

Email:*

example@example.com

Home Phone:

Please enter a valid phone number.Format: (000) 000-0000.

Cell Phone: *

Please enter a valid phone number.Format: (000) 000-0000.

Home Address:

State / Province

Postal / Zip Code

Primary Care Physician (if known):

Physician Phone:

Please enter a valid phone number.Format: (000) 000-0000.

Physician Address:

Home Address:

State / Province

Postal / Zip Code

Medicare Part B ID#:

Other Insurance:

Circle Requested Vaccine(s):

Flu ShotPneumoniaOther

The following questions will help us determine your eligibility to be vaccinated today.

For All Vaccines: Please answer questions 1-9
For Live Vaccines: Please answer questions 1-17

1. Which vaccines are you requesting to have administered today? Please list all requested vaccines:*

2. Do you feel sick today?*

YesNoDon't Know

3. Do you have allergies to medications, food or any vaccine? (Examples: Eggs, Bovine Protein, Gelatin, Gentamicin, Polymixin, Neomycin, Phenol or Thimerosal) *

YesNoDon't Know

3a. If yes, please list the allergies:

4. Have you received any vaccinations in the past 4 weeks?*

YesNoDon't Know

4a. If yes, which vaccines have you received:

5. Have you ever had a serious reaction to an influenza vaccine or any other vaccine in the past? *

YesNoDon't Know

6. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barre Syndrome (a condition that causes paralysis) or other nervous system problems?*

YesNoDon't Know

7. Are you 65 years of age or older OR do you smoke OR have a chronic condition (such as asthma or diabetes?)*

YesNoDon't Know

8. If you answered YES to question #7, have you ever had a pneumococcal, or “Pneumonia,” vaccination?*

YesNoDon't Know

9. For women: Are you pregnant or considering becoming pregnant in the next month?*

YesNoDon't Know

10. Do you have cancer, leukemia, lymphoma, HIV/AIDS or any other immune system disorder or are in contact with anyone who has a severely weakened immune system?

YesNoDon't Know

11. Are you currently on home infusions, weekly injections and/or taking medications such as Remicade®, Enbrel®, Humira®, Kineret®?

YesNoDon't Know

Please refer to your health care provider if unsure about medication history

12. Do you take cortisone, prednisone, other steroids, anticancer drugs or have had radiation treatment?

YesNoDon't Know

13. Have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin in the past year?

YesNoDon't Know

14. Are you receiving aspirin therapy or aspirin-containing therapy (18 years of age or younger)

YesNoDon't Know

15. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia or other blood disorder?

YesNoDon't Know

16. If the patient receiving vaccine is under 5 years old, does he/she have a history of asthma or wheezing?

YesNoDon't Know

17. Does the patient have a nasal condition serious enough to make breathing difficult, such as a very stuffy nose? (for FluMist® only)

YesNoDon't Know

I certify that I am: (i) the Patient and at least 18 years of age; (ii) the parent of legal guardian of the minor Patient; or (iii) the legal guardian of the Patient. Further, I hereby give my consent to the health care provider of AllCare Pharmacy, 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 complication 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 health care provider. On behalf of myself, my heirs and personal representatives, I bereby release and hold harmless AllCare Pharmacy, 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) listen above. I authorize AllCare Pharmacy, as applicable, to release any medical or other information to my health care professionals, Medicare, Medicaid or other third party payer necessary to effectuate care or payment and request that payment or authorized benefits be made on my behalf to AllCare Pharmacy, as applicable, with respect to the vaccine(s) listed above.

Signature

Date

Section A

SECTION B:

ALL VACCINES

LIVE VACCINES

Section C

Please PRINT form below for walk-ins or SUBMIT your form to schedule your appointment