VAERS ID: 958627

AGE: 17| SEX: M|STATE: CA (United States)

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.

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Symptoms

No adverse event, Product administered to patient of inappropriate age

Vaccines

VAX DATE: 01-14-2021| ONSET DATE: 01-14-2021| DAYS TO ONSET: 0
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (MODERNA)) 1 COVID19 MODERNA 037K20A IM LA

RECVDATE:01-20-2021
RPT_DATE:
CAGE_YR:17
CAGE_MO:
DIED:U
DATEDIED:
L_THREAT:U
ER_VISIT:
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
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:
TODAYS_DATE:01-20-2021
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:NKDA
V_FUNDBY:

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