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VAERS ID: 958627

AGE: 17| SEX: M|State: CA

Description

A 17yo was scheduled for vaccination via invite link shared with his parent's dental office. His parents signed consent for him to receive the vaccine and the patient was able to slip in through the system unnoticed. Pt has not reported any side effects or adverse outcomes to us.

Symptoms

No adverse event, Product administered to patient of inappropriate age

Vaccines

VAX DATE: 13 January 2021 | ONSET DATE: 13 January 2021 | DAYS TO ONSET: 0
Vaccine TypeManufacturerVaccine NameDoseRouteSiteLot
  • COVID19
  • MODERNA
  • COVID19 (COVID19 (MODERNA))
  • 1
  • IM
  • LA
  • 037K20A

RECVDATE:19 January 2021
CAGE_YR:17
CAGE_MO:
RPT_DATE:
DIED:
DATEDIED:
L_THREAT:
ER_VISIT:
HOSPITAL:
HOSPDAYS:
X_STAY:
DISABLE:
RECOVD:U
LAB_DATA:none
V_ADMINBY:PUB
OTHER_MEDS:none
CUR_ILL:12/2020: abnormal urine findings/urgency/infective urethritis, LBP
HISTORY:Acne vulgaris (Primary Dx); Medication monitoring encounter; Hypercholesterolemia; Asteatotic eczema
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:2
TODAYS_DATE:19 January 2021
BIRTH_DEFECT:
OFC_VISIT:
ER_ED_VISIT:
ALLERGIES:NKDA
V_FUNDBY:
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