How to Fill Out and Submit the Walgreens COVID-19 Vaccine Consent Form

The Walgreens COVID-19 vaccine consent form, officially the Vaccine Administration Record (VAR), is a four-section intake and consent document you complete before getting your shot. It gathers your personal details, screens your health history, captures your signature, and records how the vaccine will be billed. You can download the PDF and fill it out at home, complete it online when you book, or finish it on paper at the pharmacy counter.¹

Getting the Form Before Your Visit

The VAR is available as a downloadable PDF from the Walgreens website.¹ If you schedule your appointment through the Walgreens vaccine scheduling page, you may be prompted to complete it digitally during booking.² Walk-ins are also accepted, subject to that store’s supply and staffing on the day.³

Bring the completed form, a photo ID, and your insurance card if you have one.⁴ Filling the form out in advance is the single biggest time-saver at check-in.

Section A: Personal Information

Section A collects your first and last name, date of birth, age, gender, phone number, home address, city, state, ZIP code, and email, plus a yes/no on whether you want text alerts about prescriptions.¹ Make sure your name and date of birth match your ID exactly. Mismatches slow things down at the counter.

Two demographic fields, race and ethnicity, appear because CDC reporting guidelines require this data for public health surveillance. You can select from the listed categories or choose “Unknown” for either.

There is also an optional block for your primary care provider’s name, phone number, and address. Filling it in lets Walgreens share your vaccination record with your doctor’s office so it becomes part of your broader medical file.⁴ Finally, check the box indicating you want the COVID-19 vaccine.

Section B: Health Screening Questions

Section B is a yes/no questionnaire (currently 19 items) designed to flag conditions that might make vaccination unsafe or require extra precautions. The pharmacist reviews your answers before giving the shot. Honest answers here are what protect you from a preventable reaction.

Expect questions on whether you:

Feel sick today. A current fever or acute illness may mean rescheduling.
Have chronic conditions such as heart disease, diabetes, asthma, or an immune system disorder.
Have had an allergic reaction to any previous vaccine, not just a COVID-19 shot.
Have allergies to specific vaccine ingredients. The mRNA COVID-19 vaccines contain polyethylene glycol (PEG), and the protein subunit vaccine contains polysorbate, both known allergens for some people.⁵
Are pregnant or breastfeeding. This does not disqualify you, but the pharmacist needs to know.
Have received another vaccine recently. Timing between certain vaccines can matter.

When you answer “yes,” use the space provided to add detail. A bare “yes” without context forces the pharmacist to stop and interview you. For allergy questions in particular, note the specific reaction (hives, difficulty breathing, swelling) and which vaccine triggered it. The pharmacist uses those details to decide whether to proceed, extend your observation time, or refer you to an allergist. The CDC recommends that providers screen patients before every dose and that anyone with a true contraindication should not be vaccinated.⁶

Section C: Consent and Signature

Section C is where you sign and date the form. Your signature confirms that you have reviewed the vaccine information and consent to receive the shot, and that you are at least 18, the legal guardian of the patient, or otherwise authorized to consent on the patient’s behalf.⁷

The signature block also acknowledges that you received the Notice of Privacy Practices. Federal regulations require Walgreens to provide this notice no later than the date of your first service, explaining how your health information is used and shared.⁸ The notice is typically included with the form packet or posted at the pharmacy counter.

One update worth knowing: all four COVID-19 vaccines available for the 2025–2026 season (Spikevax, Comirnaty, MNexspike, and Nuvaxovid) received full FDA approval in August 2025.⁹ The Emergency Use Authorization fact sheets that used to be part of the consent packet have been replaced by standard FDA-approved prescribing information. If a form you receive still references an EUA fact sheet, ask the pharmacy for the current approved product information instead.

Consent for Minors

Walgreens vaccinates children ages three and older, subject to state and age restrictions.² For a patient under 18 (under 16 in South Carolina, under 19 in Nebraska, or under 21 in Puerto Rico), a parent or guardian must accompany the minor and sign Section C. The signature line is specifically labeled “Parent or guardian, if minor.”⁷ Someone who is not the parent but is legally authorized to consent, such as a court-appointed guardian, can sign, but should be ready to verify that authority if the pharmacy asks.

Section D: Insurance Information

Section D handles billing. What you enter depends on how you are covered.

Medicare Part B: enter your Medicare number and the last four digits of your Social Security number. Medicare Part B covers the 2025–2026 COVID-19 vaccines at no cost as long as your provider accepts Medicare assignment. Bring your red, white, and blue Medicare card.¹⁰
Private insurance (pharmacy card): enter the plan ID, member ID, RX BIN, RX PCN, and group number from the back of your insurance card. Most private plans cover COVID-19 vaccines as preventive care at no cost under the CARES Act and ACA preventive services requirements.¹¹
Private insurance (medical card): if your plan uses a separate medical card, enter the plan ID, member ID, and group number from that card.
Uninsured: check the box attesting that you have no medical or pharmacy insurance and provide your driver’s license or state ID number.¹

When the cardholder is not the patient (a parent covering a child, for example), initial the designated space and provide the cardholder’s name, date of birth, and relationship to the patient.

On cost for the uninsured: the federal Bridge Access Program that previously provided free COVID-19 vaccines to uninsured adults has ended. Walgreens describes the vaccines as available at “no cost” with most insurance,³ but uninsured individuals should expect an out-of-pocket charge. Retail prices at major pharmacy chains for the 2025–2026 vaccines range roughly from $154 to $250 depending on the product. If price is a concern, ask the pharmacy for your specific cost before the appointment.

At the Counter

Hand your completed VAR, ID, and insurance card to the pharmacy staff at check-in. A technician reviews the form for completeness and matches your ID to the information you entered. The pharmacist then goes over your Section B answers, asks any follow-up questions, and calls you to the immunization area.

The injection takes a few seconds into your upper arm. Afterward, you wait in a designated observation area for at least 15 minutes so the team can monitor you for any immediate allergic reaction.¹² If you reported a history of severe allergic reactions, that observation period extends to 30 minutes.¹³ Don’t leave early. Anaphylaxis is rare, but when it happens it typically appears within this window and is far easier to treat on-site.

Common side effects over the next day or two include soreness at the injection site, fatigue, headache, and mild fever. If you develop a high fever, difficulty breathing, or signs of a serious allergic reaction after leaving the pharmacy, seek medical attention immediately.

If You Have a Reaction After Leaving

You or your healthcare provider can report an unexpected or serious reaction through the Vaccine Adverse Event Reporting System (VAERS) at vaers.hhs.gov.¹⁴ VAERS is a surveillance tool, not a treatment program. For a medical emergency, call 911 or go to the emergency room first and file the report afterward.

For a serious injury you believe was caused by the vaccine, the federal Countermeasures Injury Compensation Program (CICP) is the avenue for seeking compensation. You must submit a Request for Benefits form within one year of receiving the vaccine. The initial filing does not require you to name the specific manufacturer; supporting medical records can follow. The bar is high: as of March 2026, only 95 of more than 14,000 COVID-19 claims filed with the CICP have been found eligible for compensation.¹⁵ The program requires compelling medical and scientific evidence that the vaccine directly caused the injury.

1
Walgreens. Vaccine Administration Record (VAR) – Informed Consent for Vaccination
2
Walgreens. Schedule Vaccine Appointments
3
Walgreens. Schedule Free COVID-19 Vaccines
4
Walgreens. Walgreens Employer In-Store Appointment Prep Guide
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Walgreens. Covid19 (Pfizer Pediatric Age 5-11) Drug Details
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Centers for Disease Control and Prevention. Interim Considerations: Preparing for the Potential Management of Anaphylaxis after COVID-19 Vaccination
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Walgreens. Vaccine Administration Record (VAR) – Informed Consent for Vaccination
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eCFR. 45 CFR 164.520
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ACP Journals. COVID-19 Vaccines for 2025-2026 in Adults Who Are Not Pregnant
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Medicare.gov. Coronavirus Disease 2019 (COVID-19) Vaccine
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Congress.gov. The ACA Preventive Services Coverage Requirement
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Centers for Disease Control and Prevention. Vaccine Administration: After Giving Vaccine
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Centers for Disease Control and Prevention. Running a Vaccination Clinic
14
Vaccine Adverse Event Reporting System. Vaccine Adverse Event Reporting System
15
Health Resources and Services Administration. Countermeasures Injury Compensation Program (CICP) Data