Vaccine Administration Record (VAR)

  • Vaccine Administration Record (VAR)

    Hereford Pharmacy Inc. * 216 Mt. Carmel Rd. * Parkton MD 21120 * 410-329-6209

  •  - -
  • Format: (000) 000-0000.
  • Gender (at birth)*
  • Ethnicity*
  • Race*

  • Prescription Insurance

    (Please include the information from your insurance card that covers your prescription medication. In addition, please enter your Medicare ID number from your Medicare Card if applicable in the space below) - THIS FIELD IS NOT REQUIRED
  • Which of the following vaccine(s) would you like to receive:
  • Which of the following vaccine(s) would you like to receive (for age 11):*
  • Which of the following vaccine(s) would you like to receive (for ages 12-17):*
  • Which of the following vaccine(s) would you like to receive (for age 18):*
  • Which of the following vaccine(s) would you like to receive (for ages 19 to 49):*
  • Which of the following vaccine(s) would you like to receive (for ages 50 to 59):*
  • Which of the following vaccine(s) would you like to receive (for ages 60 to 64):*
  • Which of the following vaccine(s) would you like to receive (for ages 65 to 74):*
  • Which of the following vaccine(s) would you like to receive (for ages 75+):*

  • Eligibility Questions

    Questions below will help us determine your eligibility to be vaccinated
  • Are you sick today?*
  • Do you have allergies to medications, food, a vaccine component, or latex?*
  • Have you ever had a serious reaction after receiving a vaccination?*
  • Do you have a history of thrombocytopenia (low platelets) or are you on long-term aspirin therapy?*
  • Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*
  • Do you have a parent, brother, or sister with an immune system problem?*
  • In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Chrohn's disease, or psoriasis; or have you had radiation treatments?*
  • Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barre syndrome, or other nervous system problem?*
  • During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug?*
  • For women: Are you pregnant or is there a chance you could become pregnant during the next month?*
  • Have you received any vaccinations in the past 28 days?*
  • Have you ever had a severe allergic reaction (i.e. anaphylaxis) after a previous dose or to a component of the COVID-19 vaccine?*
  • Have you ever developed myocarditis or pericarditis after a dose of an mRNA (Moderna or Pfizer-BioNTech) vaccine?*
  • Do you have a history of Multi-system Inflammatory Syndrome (MIS)?*
  • Have you recently had COVID-19 disease, either symptomatic or asymptomatic, within the last 3 months? (The CDC recommends delaying the booster dose by 3 months from symptom onset or a positive test (if infection was asymptomatic).*
  • To receive the RSV (Respiratory Syncytial Virus) vaccine I attest to at least ONE of the following:*
  • Based on the age of the patient receiving the vaccine (17 years of age or younger) I attest to one of the following statements:*

  • The following information below is to be completed by the Healthcare Provider at Hereford Pharmacy ONLY:

  • Vaccine Lot # Exp Date Dose (mL) Route Site

    COVID-19 (Pfizer-BioNTech Bivalent)

    		     0.3 IM L       R

    COVID-19 (Moderna Bivalent)

    		     0.5 IM L       R

    Influenza PFS (Afluria)

    		      0.5 IM L      R

    Influenza PFS (Fluzone HD)

    		     0.7 IM L      R

    Pneumovax-23

    		     0.5  IM L     R 

    Prevnar-20

    		     0.5 IM

     L     R  

    Shingles (Shingrix)

    		     0.5 IM L   R

    Tetantus, Diphtheria, Pertusis (Boostrix)

    		     0.5 IM L   R

     

    		         L   R

     

    		         L   R
             

    L   R

  • Vaccine Administrator:       ☐ Randy Chiat, RPh               ☐ Jessica Frasier, Pharm.D.

                ☐ Keith Pfaff, Pharm.D.         ☐ Erica Silverstein, Pharm.D.

                  ☐ Megan Pfaff, RN

     

    Vaccine Administrator Signature  __________________________________

     

    Vaccine Administration Date        ________________

  • Vaccine Information Statements (VIS):

    • For electronic versions of Vaccine Information Statements pertaining to a specific vaccine, please visit https://www.cdc.gov/vaccines/hcp/current-vis/index.html
    • Paper versions of Vaccine Information Statements can be provided to you on the day of your appointment upon request.

     

    The Day of the Appointment:

    • Arrive at the pharmacy with a photo ID no earlier than 5 minutes before your scheduled appointment

     

    • Please wear a loose fitting shirt that enables the healthcare provider access to the shoulder area for the administration of the vaccine

     

    • Please be prepared to wait near the vaccination location for approximately 15 minutes for observation by the healthcare provider following the administration of the vaccine

     

  • By signing below, I agree to the terms and conditions listed:

    I have been provided an electronic version of the Vaccine Information Statement (VIS), or will be provided a paper version of the Vaccine Information Statement (VIS) upon request, and will have had explained to me, information regarding the vaccine(s) being administered. I will have the opportunity to ask questions, either prior to my scheduled appointment, or during my scheduled appointment.

    I understand the benefits and risks of the vaccine(s) being administered. I agree to wait near the vaccination location for approximately 15 minutes for observation by the healthcare provider. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Hereford Pharmacy, its subsidiaries, divisions, affiliates, officers, directors, contractors, and employees, from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). The healthcare provider may refuse to administer vaccine(s) based on the questionnaire. I certify that I am at least 18 years old and hereby give my consent to the healthcare provider of Hereford Pharmacy to administer the vaccine(s). If the patient is under 18 years, I certify that I am the parent or guardian of the patient and give my consent to the healthcare provider of Hereford Pharmacy to administer the vaccine(s).

  • Should be Empty: