General instructions

Covid-19 Vaccination Card

> Bring this Vaccine Card to the designated immunization center on the due date
Registration No- 306831347374667362 Date- 07/03/2022
of 1st, 2nd and 3rd dose of Covid-19 vaccine.
Name- MEHEDI HASAN
Date of Birth- 10/09/2000 Age- 21 > Inform the immunization worker immediately if there is any problem / difficulty
Passport No- A03239467 Country- Bangladesh after vaccination. If necessary, bring the intended people to the nearest health
center.
House No.- BANIACHOL Town/Area- BANIACHOL
Upazila/City Corporation- Narsingdi Sadar Ward No.- 3 > Before vaccination, the vaccination center and the date of vaccination will be
Union- Narsingdi informed via SMS.
District- Narsingdi
Municipality
Center Name- Narsingdi 100 Bed Zilla Hospital > Keep the card for future use even if the vaccination is completed
Vaccinator Information
>If the vaccine card is lost, it can be downloaded from the website
Name- -
www.surokkha.gov.bd.
Center ID- 683130720
> Certificate can be collected from www.surokkha.gov.bd after completion of 2
Mobile- -
doses of Covid-19 vaccine.
Covid-19 Vaccination Information
Date of Receiving the Date of Vaccination & > Even if you get vaccinated against Covid-19, follow proper health rules.
Vaccine Dose
Vaccine Vaccinator Signature

1st Dose 09/03/2022 09/03/2022

2nd Dose 04/04/2022 19/04/2022

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

Expanded Programme on Immunization (EPI)

Dose-1: Pfizer (Pfizer-BioNTech) Directorate General of Health Services
Ministry of health and family welfare
Vaccine Name,
Manufacturer, Dose-2: Pfizer (Pfizer-BioNTech) :: In collaboration with ::
Batch Number

Dose-3: N/A

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Vaccine Recipient's Consent Paper

Registration No- 306831347374667362 Registration Date- 07/03/2022 Passport No- A03239467

Name- MEHEDI HASAN
Country- Bangladesh

> 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- ------------------------------------------------------