HOSSAIN, SABIHA (DOB: 04/09/2013 ID: 1001837745) Printed on: 04/24/2024 Printed on: 04/24/2024

Vaccine Administration Record

Best Care Medical Services P.C.

Name: HOSSAIN, SABIHA

DOB: 04/09/2013
PrintDate:4/24/2024 9:41:29 AM
Age: 11y
Gender: F

I have been provided a copy of the appropriate Centers for Disease Control and Prevention Vaccine Information Material(s) and have read, or have had explained to
me,information about the diseases and the vaccines listed below. I have had a chance to ask questions that were answered to my satisfaction.I believe I understand the
benefits and risks of the vaccines cited, and ask that the vaccine(s) listed below be given to me or to the person named above (for whom I am authorized to make this
request).

Vaccine Administration Vaccine Expiration Date of Dose Funding Information

Vaccine Age VFC Provider Location Manufacturer Site Note
Group Date Lot# Date VIS (s) Source Source
DTaP/DT/Td/Tdap 04/19/2024 Tdap(115) 11y V06 Abedin, Best U7928AA Sanofi Pasteur 11/23/2025 04/19/2024 1.00 RA vfc feb24 00
Jahidul Care (Active)
Medical
Services
P.C.
04/17/2017 DTaP-IPV 4y V02 Abedin, Best 5s5tj GlaxoSmithKline 10/19/2018 04/17/2017 1.00 RA vfcJan17 00
(130) Jahidul Care
Medical
Services
P.C.
10/09/2014 DTaP, 5 1y Abedin, Best 01
pertussis 6m Jahidul Care
antigens(106) Medical
Services
P.C.
10/09/2013 DTaP-Hep B- 6m Abedin, Best 01
IPV(110) Jahidul Care
Medical
Services
P.C.
08/09/2013 DTaP, 5 4m Abedin, Best 01
pertussis Jahidul Care
antigens(106) Medical
Services
P.C.
08/09/2013 DTaP-IPV 4m Abedin, Best 01
(130) Jahidul Care
Medical
Services
P.C.
06/11/2013 DTaP-Hep B- 2m Abedin, Best 01
IPV(110) 2d Jahidul Care
Medical
Services
P.C.
Hep A 09/18/2015 Hep A, 2y Abedin, Best 01
ped/adol, 2 5m Jahidul Care
dose(83) Medical
Services
P.C.
05/05/2014 Hep A, 1y Abedin, Best 01
ped/adol, 2 Jahidul Care
dose(83) Medical
Services
P.C.
Hep B 10/09/2013 DTaP-Hep B- 6m Abedin, Best 01
IPV(110) Jahidul Care
Medical
Services
P.C.
06/11/2013 DTaP-Hep B- 2m Abedin, Best 01
IPV(110) 2d Jahidul Care
Medical
Services
P.C.
04/18/2013 Hep B, 9d Abedin, Best 01
adolescent or Jahidul Care
pediatric(08) Medical
Services
P.C.
Hib 07/16/2014 Hib (PRP-OMP) 1y Abedin, Best 01
(49) 3m Jahidul Care
Medical
Services
P.C.
10/09/2013 Hib (PRP-OMP) 6m Abedin, Best 01
(49) Jahidul Care
Medical
Services
P.C.
08/09/2013 Hib (PRP-OMP) 4m Abedin, Best 01
(49) Jahidul Care
Medical
Services
P.C.
06/11/2013 Hib (PRP-OMP) 2m Abedin, Best 01
(49) 2d Jahidul Care
Medical
Services
P.C.
HPV 04/19/2024 HPV9(165) 11y V06 Abedin, Best X018884 Merck and Co., 04/23/2025 04/19/2024 1.00 LA vfc feb24 00
Jahidul Care Inc. (Active)
Medical
Services
P.C.

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HOSSAIN, SABIHA (DOB: 04/09/2013 ID: 1001837745) Printed on: 04/24/2024 Printed on: 04/24/2024
Influenza 09/22/2023 influenza, live, 10y V06 Abedin, Best TH2108 MedImmune, 12/19/2023 09/22/2023 1.00 IN vfc oct23 00
intranasal, Jahidul Care Inc.
quadrivalent Medical (AstraZeneca)
(149) Services (Active)
P.C.
09/18/2020 influenza, live, 7y V06 Abedin, Best mh2201 MedImmune, 12/16/2020 09/18/2020 1.00 IN vfc CHP 00
intranasal, Jahidul Care Inc.
quadrivalent Medical (AstraZeneca)
(149) Services
P.C.
11/04/2019 Influenza, 6y V06 Abedin, Best ut6653aa Sanofi Pasteur 06/30/2020 11/04/2019 1.00 RA VFC_CHP_syringe 00
seasonal, Jahidul Care
injectable, Medical
preservative Services
free(140) P.C.
10/30/2017 Influenza, 4y V06 Abedin, Best 3L9FJ GlaxoSmithKline 06/30/2018 10/30/2017 1.00 LA vfc]3yr 00
seasonal, Jahidul Care
injectable, Medical
preservative Services
free(140) P.C.
11/03/2016 Influenza, 3y V02 Abedin, Best U5691AA sanofi pasteur 06/30/2017 08/07/2015 1.00 RA VFC]3yr 00
seasonal, 6m Jahidul Care
injectable, Medical
preservative Services
free(140) P.C.
09/23/2015 influenza, 2y Abedin, Best 01
injectable, 5m Jahidul Care
quadrivalent, Medical
preservative Services
free(150) P.C.
10/09/2014 influenza, 1y Abedin, Best 01
injectable, 6m Jahidul Care
quadrivalent, Medical
preservative Services
free(150) P.C.
11/06/2013 influenza, 6m Abedin, Best 01
injectable, 28d Jahidul Care
quadrivalent, Medical
preservative Services
free(150) P.C.
Meningococcal 04/19/2024 meningococcal 11y V06 Abedin, Best U7945BA Sanofi Pasteur 03/31/2026 04/19/2024 1.00 LA vfc feb24 00
conjugate Jahidul Care (Active)
quadrivalent, Medical
MenACWY-TT Services
(MCV4)(203) P.C.
MMR/Measles/Rubella 07/16/2014 MMR(03) 1y Abedin, Best 01
3m Jahidul Care
Medical
Services
P.C.
Pneumococcal 05/05/2014 Pneumococcal 1y Abedin, Best 01
conjugate PCV Jahidul Care
13(133) Medical
Services
P.C.
01/24/2014 Pneumococcal 9m Abedin, Best 01
conjugate PCV 15d Jahidul Care
13(133) Medical
Services
P.C.
08/09/2013 Pneumococcal 4m Abedin, Best 01
conjugate PCV Jahidul Care
13(133) Medical
Services
P.C.
06/11/2013 Pneumococcal 2m Abedin, Best 01
conjugate PCV 2d Jahidul Care
13(133) Medical
Services
P.C.
Polio 04/17/2017 DTaP-IPV 4y V02 Abedin, Best 5s5tj GlaxoSmithKline 10/19/2018 04/17/2017 1.00 RA vfcJan17 00
(130) Jahidul Care
Medical
Services
P.C.
10/09/2013 DTaP-Hep B- 6m Abedin, Best 01
IPV(110) Jahidul Care
Medical
Services
P.C.
08/09/2013 DTaP-IPV 4m Abedin, Best 01
(130) Jahidul Care
Medical
Services
P.C.
06/11/2013 DTaP-Hep B- 2m Abedin, Best 01
IPV(110) 2d Jahidul Care
Medical
Services
P.C.
Rotavirus 08/09/2013 rotavirus, 4m Abedin, Best 01
monovalent Jahidul Care
(119) Medical
Services
P.C.
06/11/2013 rotavirus, 2m Abedin, Best 01
monovalent 2d Jahidul Care
(119) Medical
Services
P.C.
Varicella 05/05/2014 varicella(21) 1y Abedin, Best 01
Jahidul Care
Medical
Services
P.C.
COVID-19 01/18/2022 COVID-19, 8y FK5618 Pfizer 07/28/2022 05

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HOSSAIN, SABIHA (DOB: 04/09/2013 ID: 1001837745) Printed on: 04/24/2024 Printed on: 04/24/2024
mRNA, LNP-S,
PF, 10
mcg/0.2 mL
dose, tris-
sucrose(218)
12/18/2021 COVID-19, 8y FK5168 Pfizer 07/28/2022 05
mRNA, LNP-S,
PF, 10
mcg/0.2 mL
dose, tris-
sucrose(218)

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