COVID-19 Vaccination Card

Please keep this record card, which includes medical information Card ID no.
about the vaccines you have received.
1112529

Ballad Teodoro Baccay

Last Name First Name M.I. Suffix

45813003 SAN ISIDRO, 45813 TAYTAY,

Address Contact No. 9659110118
0458 RIZAL, CALABARZON

Date of Birth 11/09/1959 Sex m Philhealth No. N/A Category A4

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

1st Dose Schedule 10/02/2021 Moderna 3005784

Vaccinator Name: STEFANY M. FLORA

2nd Dose Schedule 10/30/2021 Moderna 3005784

Vaccinator Name: Laarni Manaloto

Health Facility Name (1st SIVC 3 Contact No.: +6300000000

Dose):

Health Facility Name (2nd SIVC 3 Contact No.: +6300000000

Dose):