Name : ABDUL MUIS ROHAN BASRI

LAIYYA
Date Of : 31 Jan 1978
Birth
Sex : Male
Nationality : INDONESIA
1. Vaccine or prophylaxis : Date :
Meningitis Meningococcus ACYW135 08 May 2023

Manufacture and batch of vaccine : Valid until :

J202209002 07 May 2025

Signature and professional status of supervising Official Stamp

clinician : :

2. Vaccine or prophylaxis : Date :

COVID-19 1st Dose 20 Sep 2021

Manufacture and batch of vaccine : Valid until :

24005321

Signature and professional status of supervising Official Stamp

ABDUL MUIS ROHAN BASRI clinician : :

LAIYYA 3. Vaccine or prophylaxis :

COVID-19 2nd Dose
Date :
21 Apr 2022
KOTA JAYAPURA Manufacture and batch of vaccine : Valid until :
2021091500
2600017958
 Signature and professional status of supervising Official Stamp
clinician : :