NCulcleasure NYSIIS 2021.11.15.pdf

11/15/2021 New York State Immunization Information System SUFFOLK COUNTY DEPT OF HEALTH Immunization History Report Patient ID:...

11/15/2021 New York State Immunization Information System SUFFOLK COUNTY DEPT OF HEALTH Immunization History Report Patient ID: Tracking Schedule: ACIP Patient Name: NATASHA CULCLEASURE Birth Date: 10/19/1978 Gender: Female Address: 25 COUNTRY CLUB DR APT A City: CORAM State: NY ZIP: 11727-3434 Phone: (631) 633-9598 Age: 43 years, 27 days Vaccine [Trade Mfg Provider of Immun Date Admin Series Dose Lot # Bod Rt. Bod St. React Name] Code Information COVID-19, mRNA,LNP-S,PF, COVID-19 04/27/2021 1 of 2 Full PFR ER8736 IM LD Suffolk County DOH - 0.3mL [PfizerCovid- 19Comirnaty ®] COVID-19, mRNA,LNP-S,PF, COVID-19 05/24/2021 2 of 2 Full EW0191 IM LA STC HUB - Walmart 0.3mL [PfizerCovid- 19Comirnaty ®] Reaction Descriptions: No Records Found. Patient Comments: Start Date: End Date: No Records Found. Organization Name: Address: City: State: ZIP: Phone: null Primary Care Provider: Provider's Signature: Date: NATASHA CULCLEASURE 1 of 1 DOB: 10/19/1978