Get In-store Use Only Walmart And Sam's Club Vaccine Administration Record And Informed Consent 2020-2025

Filling out the vaccine administration record and informed consent form is an essential step for receiving immunizations at Walmart or Sam's Club. This guide will provide you with clear instructions on how to complete the form accurately and efficiently.

Follow the steps to complete the vaccine administration record and informed consent form.

1. Click ‘Get Form’ button to access the vaccine administration record and informed consent form and open it in your document editor.
2. In Section A, please print your first and last name clearly. Indicate your gender by marking the appropriate box. Fill in your date of birth and race/ethnicity. Also, provide your mother's maiden name and home address, including city, state, and zip code. Lastly, enter your phone number.
3. Indicate whether you have a Primary Care Provider. If yes, provide their name and street address for communication regarding your immunization information.
4. Select the vaccine you have requested from the provided options. Ensure you mark the correct vaccine for your needs.
5. In Section B, answer the eligibility questions listed. Carefully consider each question regarding your health history and current medications. Mark 'YES' or 'NO' as appropriate.
6. In Section C, read the consent statement thoroughly. After understanding the benefits and risks, sign and date the form, acknowledging your consent for the vaccine administration. Initial next to each of the acknowledgments mentioned.
7. Section D is to be filled out by the healthcare provider. Ensure the provider completes all necessary fields, including immunizer's name, signature, and details about the vaccine administered.
8. Once the form is completely filled out, review all entries for accuracy. After verifying information, save your changes, and download, print, or share the form as needed.

Complete your vaccine administration record online today to ensure a smooth immunization process.