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From the 9/3/2021 release of VAERS data:

This is VAERS ID 1430585



Case Details

VAERS ID: 1430585 (history)  
Form: Version 2.0  
Age: 12.0  
Sex: Female  
Location: Texas  
Vaccinated:2021-06-26
Onset:2021-06-26
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-06-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0176 / 1 LA / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Anaphylactic shock, Dizziness, Eye movement disorder, Loss of consciousness, Nasopharyngitis, Pallor, Syncope, Unresponsive to stimuli
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Anaphylactic/anaphylactoid shock conditions (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Vestibular disorders (broad), Ocular motility disorders (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: NA
Current Illness: NA
Preexisting Conditions: NA
Allergies: NKDA, NA - food allergies
Diagnostic Lab Data: Epipen 0.3 MG IM left thigh (anterior) administered on 6/26/21
CDC Split Type:

Write-up: Within minutes after receiving 1st dose of Pfizer-BioN Tech covid Vaccine 0.3 ml IM, patient complained of dizziness and fell to the ground. Patient was very pale and cold to touch, not being responsive well. Patient was losing consciousness and having difficulty keeping her head up. Patient was moved to lie down on the floor with legs up. Cold water was offered and patient took a few sip. EMS was called. Patients eyes rolled back into her head and lost consciousness/possible anaphylactic shock and not being responsive. Epipen 0.3 MG IM administered. Patient regained consciousness. Nurse practitioner was called and vitals including BP and oxygen level was performed and found to be stable. EMS arrived in few minutes and vitals were checked again by EMS personnel and patient was transferred out to nearby ER. After 3 and 1/2 hours at the ER for observation, patient was discharged.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1430585


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