General instructions

Covid-19 Vaccination Card

> Bring this Vaccine Card to the designated immunization center on the due date
Registration No- 508149547212708277 Date- 23/07/2021
of 1st, 2nd and 3rd dose of Covid-19 vaccine.
Name- SAKIB MD. ASIF
Date of Birth- 28/11/1995 Age- 25 > Inform the immunization worker immediately if there is any problem / difficulty
Passport No- after vaccination. If necessary, bring the intended people to the nearest health
Country- Bangladesh center.
BP0057094
House No.- বহরমপুর Town/Area- বহরমপুর
> Before vaccination, the vaccination center and the date of vaccination will be
Upazila/City Corporation- Rajshahi city corporation Ward No.- 3 informed via SMS.
District- Rajshahi Union- rajpara
Center Name- Rajshahi Medical College 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- 814950776
> 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 27/07/2021 27/07/2021

2nd Dose 23/08/2021 31/08/2021

With your cooperation, the Government of Bangladesh is committed to deliver the Covid-19
vaccine to all who are targeted.
3rd Dose 03/03/2022 05/03/2022

Expanded Programme on Immunization (EPI)

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

Dose-3: Moderna (Moderna)

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Vaccine Recipient's Consent Paper

Registration No- 508149547212708277 Registration Date- 23/07/2021 Passport No- BP0057094

Name- SAKIB MD. ASIF
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- ------------------------------------------------------