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This is VAERS ID 1368003

History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1368003
VAERS Form:2
Age:80.0
Sex:Male
Location:Nebraska
Vaccinated:2021-06-01
Onset:2021-06-01
Submitted:0000-00-00
Entered:2021-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 033C21A / 3 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Extra dose administered, No adverse event

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Unknown
Current Illness: None Reported
Preexisting Conditions: None Reported
Allergies: None Reported
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Patient presented at the pharmacy asking to receive his Moderna Covid-19 immunization. Patient stated it was his first shot. Moderna vaccine administration was billed through Medicare. Vaccine was administered to patient. Patient was monitored for 15 minutes with no apparent reaction. When pharmacy technician attempted to add the vaccination information, it was discovered that patient had 2 previous Moderna Covid-19 vaccines reported on 2/11/2021 and 3/11/2021. Dr. was notified of the 3rd dose administered. Nurse stated she would report it. Called and left a message with the patient to call. No return call has been received at this time.

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