COVID-19 VACCINATION RECORD CARD

Please keep this record card, which includes medical information about the
vaccines you have received.
First Name: ------------------------------------------------ Last Name: --------------------------------------------
Age / DOB: ------------/------------------------------------ Insurance No: ----------------------------------------
Patient Number: ------------------------------------------- Gender: ------------------------------------------------
Allergies: -----------------------------------------------------------------------------------------------------------------

Product Healthcare
Vaccine /Manufacturer Date Professional or
Lot Number Clinic Site
1st Dose COVID-19

1st Dose COVID-19

1st Dose COVID-19

1st Dose COVID-19

Medical Director (or another authorized practitioner)

Name:--------------------------------------- Signature:-------------------------------