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This is VAERS ID 1454556

History of Changes from the VAERS Wayback Machine

First Appeared on 7/9/2021

VAERS ID: 1454556
VAERS Form:2
Age:11.0
Sex:Male
Location:Illinois
Vaccinated:2021-07-07
Onset:2021-07-07
Submitted:0000-00-00
Entered:2021-07-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EW0178 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Product administered to patient of inappropriate age

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: N/A
Current Illness:
Preexisting Conditions:
Allergies: N/A
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient''s mother misinformed us about patient''s age. Listed on form as incorrect DOB when actual birthday is exact date. Mother verbally confirmed the incorrect birthday several times during the visit. Issue was discovered at the time of billing when the insurance informed us of the exact date birthday. When we called the mother back to confirm which is correct, she admitted to putting the wrong birthdate on the form. We informed her that the patient cannot get a follow up immunization until after the actual date of birth.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1454556&WAYBACKHISTORY=ON


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