Clinical services provided and/or recorded by Harris Health System, Houston, Texas 77054.

Record/Results Printed: 01/14/2021 09:48 am

Participant Name: Casby, Kelly Date of Birth: 08/29/1957 Gender: M

Corporate HR ID: 113602

COVID-19 (SARS-COV-2) IMMUNIZATION RECORD

Appointment Date 01/08/2021 18:34 12/21/2020 00:00

COVID-19 vaccination performed: AS PART OF THIS ENCOUNTER AS PART OF THIS
ENCOUNTER
Education: Vaccination Information Statement (VIS) given? YES YES
Medical history reviewed and consent received from employee? YES YES
Select location where the vaccine was administered: HARRIS HEALTH SYSTEM EHS
LBJ
Was the product stored at the required temperature as specified by the manufacturer? YES YES
Did the employee consent to have their immunization information shared with the state registry? YES YES
Did the employee consent to have their immunization information shared with their personal Electronic Health YES YES
Record?
Administration site: LEFT ARM LEFT ARM
Administered by: Esther Castillo 92668 Taylor Washington, RN
Time vaccine administered: 18:37 07:54
Dose administered this visit (or latest dose from prior documentation): SECOND DOSE FIRST DOSE
Date vaccine administered: 01/08/2021 12/21/2020
Date of next vaccination (if required): 01/10/2021
Has employee experienced an adverse reaction to any COVID-19 vaccine product? NO NO
Ethnicity: NOT HISPANIC OR LATINO NOT HISPANIC OR LATINO
White WHITE WHITE
Does the employee have any chronic illnesses? NO NO
Immunity status: UNKNOWN UNKNOWN
Signed by: Geraldine Binion Lori Cummings
Date signed: 01/08/2021 12/21/2020
Product Name Pfizer-BioNTech COVID-19 Pfizer-BioNTech COVID-19
Vaccine Vaccine
Dose Form 0.3mL 0.3mL
Lot Number EL1283 EK5730
 CVX Code 208 208
CPT 4 Code 91300 91300
Route Intramuscular Intramuscular
Presentation Multi-dose vial Multi-dose vial
Dose Administered 0.3mL 0.3mL
VIS Date 12/11/2020 12/11/2020
Manufacturer Pfizer Pfizer
Product ID 31462 31462
Expiration Date 04/30/2021 03/31/2021

This Electronic Health Record was generated by the ReadySet Employee Health System.
This Electronic Health Record contains personal health information and is intended for authorized healthcare personnel only.
Contact Harris Health Employee Services for more information.
Barbara Aguirre

From: Kelly Casby <kellycasbyrn@gmail.com>

Sent: Monday, May 2, 2022 12:01 PM
To: Barbara Aguirre
Subject: Fwd: For Your Records

---------- Forwarded message ---------

From: CVS Pharmacy <pharmacy@notification.cvshealth.com>
Date: Mon, May 2, 2022, 11:59 AM
Subject: For Your Records
To: <KELLYCASBYRN@gmail.com>

Please keep this for your records

Hi KELLY,

Thanks for choosing CVS Pharmacy®. This email contains a record of

your recent vaccination.

If you’re 18 or older, you can view this and other CVS Pharmacy or
MinuteClinic health records in your health dashboard. To access
vaccination records for a minor, you first have to add them to your account
by requesting to manage their prescriptions through your pharmacy
dashboard.

View Record

Vaccine administration record

Patient information

1
Last name:
CASBY
First name:
KELLY

Date of birth:
08/29/1957
Gender:
M

Address:
11215 JADESTONE CREEK LN
CYPRESS, TX 77433
Phone:
(281) 606-5665

Primary care provider (PCP):

PAUL SHEPARD
PCP address:
10720 BARKER CYPRESS RD
CYPRESS, TX 774331372

Vaccine administration information

Vaccine type:
COVID
Vaccine administered:
PFIZER COVID-19 VACCINE-PURPLE

Administration date:
10/07/2021

Manufacturer:
PFIZER MANUFACT

2
Lot #:
301458a

Expiration date:
11/2021
Route:
IM

Site:
Left Deltoid
Volume (ml):
0.3ml

Vaccine Information Statement version date:

09/22/2021
Date Vaccine Information Statement given to patient:
10/07/2021

Verifying pharmacist:
Shivakumar,Srikanth
Signature electronically captured
Administering immunizer name and title:
Shivakumar, Srikanth, RPh

Vaccine prescriber:
SHAUN GILL
Vaccine prescriber address:
595 WEST STATE STREET
DOYLESTOWN, PA 18901

Store information

Store #:
02121
Rx #:
1402509

3
Address:
6601 NORTH BROAD STREET
PHLDPHIA, PA 19126
Phone:
(215) 924-1633

Need a more detailed record?

The summary above and online may not include complete information or
serve as proof of vaccination in some states. If your state needs more
details, try the following options:

A. If you signed a vaccination consent form on paper, we gave you a

paper copy of your official Vaccine Administration Record

B. If you gave us your primary care provider's information, contact

them for a copy

C. See if your state has an immunization registry

D. Call CVS Pharmacy

Report side effects and help keep the vaccine safe

The CDC has created a way for you to report how you feel after the
COVID-19 vaccination through a smartphone-based tool that uses text
messaging and web surveys to check in with you.

Sign up for v-safe today

How was your vaccine experience?

Take 1 minute to rate your vaccination experience with CVS
Pharmacy and share your thoughts.

4
Consent for services
CONSENT FOR SERVICES: I have received and read (or had read to
me) the Vaccine Information Statement(s), Vaccine Information Fact
Sheet(s) and/or Patient Fact Sheet(s) regarding the vaccine(s). I
understand the benefits and risks of vaccination. I voluntarily assume full
responsibility for any reactions or consequences that may result. I
understand that I should remain in the vaccine administration area for 15
minutes, or longer if directed, after the vaccination to be monitored for
potential adverse reactions. In the event of side effects, I understand I
should call the pharmacy, my doctor, or 911. I certify that the information
provided regarding eligibility for the vaccine is accurate and request that
the vaccine be given to me or to the person previously named for whom I
am authorized to make this request. If I am signing on behalf of another
individual (including a minor), I attest that I have the authority to do so.
Please note the following must have the consent of a parent or guardian:
Patients in Alabama/Nebraska under 19 years old; patients in South
Carolina under 16 years old; and patients under 18 years old in all other
states. If I am receiving a COVID-19 third dose, I attest that I am eligible
for that dose because I am immunocompromised. State of Georgia only: I
verify a pharmacist asked for my health history and whether I have had a
physical exam within the past year. Health care providers did not identify
conditions(s) that would mean I should not receive vaccine(s).

AUTHORIZATION TO REQUEST PAYMENT: I authorize CVS Pharmacy®

("CVS®") to release medical information to Medicare, Medicaid or any
other third party payer as needed and to request payment of authorized
benefits to be made on my behalf to CVS. I certify that the information
provided about my Medicare, Medicaid or other coverage is correct.

ACCEPTANCE OF FINANCIAL RESPONSIBILITY: Notwithstanding

anything previously set forth, I agree that I am responsible for and will
promptly pay on demand any and all obligations to CVS Pharmacy
including all self-pay balances as well as those charges for services not
covered or disallowed by my insurance carrier (For non-COVID-19
vaccines).

DISCLOSURE OF RECORDS: I understand that CVS ® may be required to

or may voluntarily disclose my health information with respect to this
vaccine to my healthcare providers, my insurance plan, health systems
and hospitals, and/or state or federal registries. I understand that CVS will
use and disclose my health information as set forth in the CVS Notice of
Privacy Practices (copy is available in-store, online or by requesting a
paper copy from the pharmacy). State of California only: I agree to have
the California Immunization Registry (CAIR) share my immunization data

5
with health care providers, agencies or schools. State of FL only: Students
18-23 may opt out of the immunization registry by notifying pharmacy prior
to administration Vaccine Clinics: If I am receiving a vaccine through a
vaccine clinic, I understand that my name, vaccine appointment date and
time will be provided to the clinic coordinator.

Signature electronically captured

Consent date:

Screening questions
Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something?
For example, a reaction for which you were treated with epinephrine or
EpiPen®, or for which you had to go to the hospital? If yes, what are you
allergic to?
N

Have you ever had a severe allergic reaction after receiving a COVID-19
vaccine?
N

Have you ever had a severe allergic reaction after receiving Polyethylene
Glycol?
N

Have you ever had a severe allergic reaction related to receiving Polysorbate
or products containing Polysorbate?
N

Have you received monoclonal antibodies or convalescent plasma as part of a

COVID-19 treatment in the past 90 days?
N

Do you have a history of an immune-mediated syndrome characterized by

thrombosis (abnormal blood clots) and thrombocytopenia (low platelets), such
as heparin- induced thrombocytopenia (HIT)?
N

Do you have a history of myocarditis (inflammation of the heart muscle) or

pericarditis (inflammation of the lining around the heart) either related to or
unrelated to receipt of an mRNA COVID-19 vaccine?

6
 N

Are you moderately/severely immunocompromised from a medical

condition/immunosuppressive therapy, including/not limited to: active
treatment for solid tumor/hematologic malignancy, solid organ/stem-cell
transplant, primary immunodeficiency syndrome, advanced/untreated HIV
infection, or active treatment with high dose corticosteroids/other
immunosuppressive/immunomodulatory biologic agents?
N

Do you have a history of Guillain-Barré syndrome (GBS)?

N

Pharmacist notes:
Patient's Temperature: 94.9f

Private and confidential. Intended for patient or caregiver only. If you have received
this document in error, please notify CVS Pharmacy immediately.

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