COVID-19 Vaccination Record Card

Please keep this record card, which includes medical information

about the vaccines you have received
Por favor, guarde esta tarjeta de registro, que incluye información
médica sobre las vacunas que ha recibido.
Last Name First Name MI

Asmat Carmen
Date of birth Patient number (medical record or NS record number)
03/16/1965
Product Name/Manufacturer Healthcare Professional or
Vaccine Date
Lot Number Clinic Site

1° Dose PFIZER 07 06 21
COVID-19 mm dd dd
Walgreens 12406
Ew0198
2° Dose PFIZER 07 30 21
COVID-19 mm dd yy Wae 112400
FA7485
Other PFIZER 01 24 22 Contigo Pharmacy
FJ6369 mm dd yy

Other mm dd yy