General instructions

Covid-19 Vaccination Card

> Bring this Vaccine Card to the designated immunization center on the due date
Registration No- 302649346852614659 Date- 13/07/2021
of 1st, 2nd and 3rd dose of Covid-19 vaccine.
Name- Sabiha Shakil
Date of Birth- 08/10/1957 Age- 63 > Inform the immunization worker immediately if there is any problem / difficulty
Passport No- AT5167552 Country- Pakistan after vaccination. If necessary, bring the intended people to the nearest health
center.
House No.- Tongi Town/Area- Tongi
Upazila/City Corporation- Dhaka North City Corporat Ward No.- 1 > Before vaccination, the vaccination center and the date of vaccination will be
District- Dhaka Union- uttara informed via SMS.
Center Name- Sheikh Russel National Gastroliver Institute & Hospital
> Keep the card for future use even if the vaccination is completed
Vaccinator Information
Name- -
>If the vaccine card is lost, it can be downloaded from the website
Center ID- 264930978 www.surokkha.gov.bd.
Mobile- -
> Certificate can be collected from www.surokkha.gov.bd after completion of 2
Covid-19 Vaccination Information doses of Covid-19 vaccine.
Date of Receiving the Date of Vaccination &
Vaccine Dose
Vaccine Vaccinator Signature > Even if you get vaccinated against Covid-19, follow proper health rules.

1st Dose 03/03/2021 03/03/2021

2nd Dose 06/05/2021 06/05/2021

3rd Dose 22/01/2022 With your cooperation, the Government of Bangladesh is committed to deliver the Covid-19
vaccine to all who are targeted.

Dose-1: COVISHIELD (AstraZeneca) Expanded Programme on Immunization (EPI)

Directorate General of Health Services
Vaccine Name, Ministry of health and family welfare
Manufacturer, Dose-2: COVISHIELD (AstraZeneca)
Batch Number :: In collaboration with ::

Dose-3: N/A

----------------------------------------------------------------------------------------------------

Vaccine Recipient's Consent Paper

Registration No- 302649346852614659 Registration Date- 13/07/2021 Passport No- AT5167552

Name- Sabiha Shakil Country- Pakistan
> Information about the Covid-19 vaccine has been explained to me online and face-to-face.
> I do agree to provide information about vaccination and its effects when required.
> In my knowledge, I don't have any drug allergies.
> I hereby providing my consent for the preparation of post-vaccination report / research paper.
> I hereby voluntarily agree to get vaccinated, knowing the benefits and side effects of this vaccine (swelling at the site of vaccination, mild fever, headache,
nausea, headache and body aches).

Signature of the Vaccine recipients ------------------------------------------------------ Date- ------------------------------------------------------