Name : ELI SUSTIANI BINTI SIARI

Date Of Birth : 18 Oct

1966 Sex : Female
Nationality : INDONESIA
1. Vaccine or prophylaxis : Date :
Meningitis Meningococcus ACYW135 01 Apr 2022

Manufacture and batch of vaccine Valid until :

: j201912004 31 Mar 2024

Signature and professional status of Official Stamp

supervising clinician : :

2. Vaccine or prophylaxis Date :

: COVID-19 1st Dose 09 Sep 2021

Manufacture and batch of vaccine Valid until :

: k0044

Signature and professional status of Official Stamp

supervising clinician : :

3. Vaccine or prophylaxis Date :

: COVID-19 2nd Dose 16 Dec 2021

Manufacture and batch of vaccine Valid until :

: n001a

Signature and professional status of Official Stamp

supervising clinician : :