COVID-19 Vaccination Card

Please keep this record card, which includes medical information

about the vaccines you have received. ID 1514399

Ballad Raymond Delos Santos

Last Name First Name M.I. Suffix

San Idiro, 045813000Taytay,

Address 045800000Rizal, REGION IV-A Contact No. 9471973109
(CALABARZON)

Date of Birth 05/03/1992 Sex M Philhealth No. N/A Category A4

Dosage Seq. Date Vaccine Manufacturer Batch No. Lot No.

1st Dose Vaccinated Outside of eZVax

2nd Dose Schedule

Vaccinator Name:

Booster Dose Schedule 01/16/2022 Moderna 010G21B

Vaccinator Name: Mark Christian P. Arce

Health Facility (1st Dose): Vaccinated Outside of eZVax Contact No.: 0000000000

Health Facility (2nd Dose): Contact No.: 0000000000

Health Facility (Booster): SIVC 3 Contact No.: 0000000000