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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 | |
| Date of birth | Patient number (medical record or IIS record number) | ||
| Vaccine | Product name/Manufacturer | Date | Healthcare Professional or Clinic Site |
|---|---|---|---|
| Lot number | |||
| 1st Dose COVID-19 |
____/____/____ ____mm ____dd ____yy |
||
| 2nd Dose COVID-19 |
____/____/____ ____mm ____dd ____yy |
||
| Other | ____/____/____ ____mm ____dd ____yy |
||
| Other | ____/____/____ ____mm ____dd ____yy |
||
