VAERS ID: 1888157

AGE: 4| SEX: F|STATE: TX (United States)

Description

Patient's mother filled out the forms for the patient claiming they were born in 2016. I found out they were born in 2017 after returning to pharmacy to type in the VAR. I changed DOB in system assuming mom was right then insurance rejected for DOB, I called mother and she admitted that she placed 2016 on the forms. so a 4 y/o received a shot. nothing adverse reported, but a 4 year old received ped Pfizer approved for 5-11. I did place a call to the Dr and reported into our internal system.

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Symptoms

No adverse event, Product administered to patient of inappropriate age

Vaccines

VAX DATE: 11-19-2021| ONSET DATE: 11-19-2021| DAYS TO ONSET: 0
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (PFIZER-BIONTECH)) 1 COVID19 PFIZER\BIONTECH FK5127 IM RA

RECVDATE:11-20-2021
RPT_DATE:
CAGE_YR:4
CAGE_MO:
DIED:U
DATEDIED:
L_THREAT:U
ER_VISIT:
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
RECOVD:U
LAB_DATA:
V_ADMINBY:OTH
OTHER_MEDS:
CUR_ILL:
HISTORY:
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:
TODAYS_DATE:11-20-2021
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:
V_FUNDBY:

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