VAERS ID: 1843655

AGE: 11| SEX: M|STATE: WI (United States)

Description

Patient was registered online for adult covid appointment with dob of 10/09/2009. Age would be 12. At time of appointment, age and dob was verified and confirmed. MD office contacted us 11/4/21 to verify adult dose was given. We confirmed dob with MD office and confirmed false information was given at time of appointment.

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Symptoms

Incorrect dose administered

Vaccines

VAX DATE: 11-02-2021| ONSET DATE: 11-04-2021| DAYS TO ONSET: 2
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (PFIZER-BIONTECH)) 1 COVID19 PFIZER\BIONTECH FH8020 IM LA

RECVDATE:11-04-2021
RPT_DATE:
CAGE_YR:11
CAGE_MO:
DIED:U
DATEDIED:
L_THREAT:U
ER_VISIT:
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
RECOVD:U
LAB_DATA:
V_ADMINBY:PHM
OTHER_MEDS:
CUR_ILL:
HISTORY:
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:
TODAYS_DATE:11-04-2021
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:
V_FUNDBY:

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