What Is Walgreens Vaccination Consent Form?
Walgreens is one of the largest pharmacy store chains in the United States. They also administer the vaccination to the public by partnering with health care providers. In order to get vaccinated at Walgreens, a vaccination consent form must be signed.
This consent form is for the patient to declare that they know all the information about the effects of the vaccine that is about to be administered and they will not hold the health care provider responsible for any after-effects of the vaccination. The health care provider should also include all the particulars of the vaccine.
What Are the Details Included in the Walgreens Vaccination Consent Form?
The Walgreens vaccination consent form has four sections, of which, first three are to be filled by the patient and the last section is to be filled by the health care provider. The information to be filled in the Walgreens vaccination consent form are as follows:
Information to be filled by the patient:
- Personal information - Name, age, date of birth, gender, race/ethnicity, and address information of the patient.
- Contact details - Mobile number, landline number, and email address details are to be entered here.
- Primary care physician details - Name, address, and contact details of the primary care provider are to be mentioned here.
- Vaccination eligibility - Depending on the vaccine that is being requested for, a set of questions are to be answered by the patient. This will help the health care provider to know whether the person is eligible or physically fit to get the immune shot that day.
- Declaration - The declaration statement needs to be consented to and agreed to by the patient by signing the form.
Information to be filled by the health care provider:
- Vaccine details - Before vaccinating the patient, the vaccine administration information is to be filled here including the vaccine injection route, dosage, vaccine lot number, and expiration date.
- Needle details - Before vaccinating the patient, the details of the needle that will be used to vaccinate should be marked here that includes needle type and the age for which it can be used.
- Declaration - The healthcare provider must state if he has verified certain important eligibility criteria before administering the vaccine.
- Vaccination details - After the immunization is done, the details of the vaccine, site of vaccinating, VIS published date, and so on are to be recorded.
- Immunizer authorization - Name and qualification of the immunizer and date particulars of the vaccination are included here.
How to Fill the Walgreens Vaccination Consent Form?
Filling the Walgreens vaccination consent form is very simple. The below instructions can help you in filling the form easily.
Step 1 - Download the Walgreens vaccination consent form from CocoDoc free of cost by clicking on the 'Get Form' button on this page.
Step 2 - The text box fields can be used to type the names, addresses, and other texts on the form.
Step 3 - To choose one from the multiple options for certain sections, you can simply click on the appropriate checkboxes and it will be highlighted.
Step 4 - To fill the date fields, click on the calendar icon on the date boxes and choose the required date from the drop-down calendar.
Step 5 - You can sign the document digitally using the digital signature feature available on the CocoDoc online PDF editor.
What Is the Walgreens Vaccination Consent Form Used for?
The Walgreens Vaccination Administration Record (VAR) informed consent form is used by health care providers to obtain written authorization from the patient who is about to get immunized.
This consent form includes details of the vaccine and will require the patient to acknowledge that all the information about the vaccination process, effects, and adverse reactions are explained to them.
Only upon giving the consent that all the risks and reasons are understood and the health care provider holds no responsibility in case of any issues after the vaccination, the vaccine will be administered. The health care provider also must record all the particulars about the vaccine and authenticate if the eligibility criteria are met for safe immunization.
