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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 medica sobre las vacunas que ha recibido.
Last Name
Datę of birth Patient number (medicalrecord orllS recordnumber)
Vaccine |
Product Name/Nlanufacturer Lot Number |
Datę |
Healthcare Professional or Clinic Site |
1st Dose |
y_i2£jz\ |
VJIC<V1 | |
COVID-19 |
................... ........1 -t ................................ Fl c\nxDz? |
mm dd yy | |
2nd Dose |
^ t( | ||
COVID-19 |
WJ li4g |
mm dd yy | |
Other |
/ / mm dd yy |