Please note all adverse event reported here must also be reported in VAERS system
Immunization Information
Patient Medical Facility : {{editDoseData.administeredFacilityName}}
Date Received : {{editDoseData.dateReceived}}
Reason for Visit : {{editDoseData.reasonForVisitDesc}}
Vaccine ID : {{editDoseData.vaccineId}}
Administration Route : {{editDoseData.vaccAdminRouteDescr}}
Administration Site : {{editDoseData.vaccAdminSiteDescr}}
Combo : {{editDoseData.combo}}
Lot Number : {{editDoseData.lotNumber}}
Date Added : {{editDoseData.dateCreated}}
Adverse Event Information
Details (Check All Appropriate)
Relevant Diagnostic Tests/Lab Data