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Vaccine Administration Record (VAR)—Informed Consent for ...

1~ - - Vaccine Administration Record (VAR) Informed Consent for Vaccination If the patient is requesting a fu vaccination, indicate the patient s age group: Under age 65 Age 65 or older OFF-SITE CLINIC BILLING GROUP: Store number: Rx number: Store address: SECTION A Please print clearly. First name: Last name: Date of birth: Age: Gender: Female Male Phone: I wish to receive text message alerts regarding my prescriptions. Home address: City: State: ZIP code: Email address: Race: American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White Other Race Unknown Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown ethnicity Walgreens will send vaccination information from this visit to your doctor/primary care provider using the contact information provided below.

16. Do you have a history of thymus disease (including myasthenia gravis, DiGeorge syndrome or thymoma), or had your : Yes No: Don’t know : thymus removed? (yellow fever only) 17. Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only) Yes; No Don’t know : 18. Have you consumed any food or drink in the last hour ...

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