Language
English (US)
Spanish (Latin America)
Haitian Creole
COVID-19 Vaccine Registration Form
Please fill out the form and we will contact you with the date and time of your appointment
Full Name
*
First Name
Last Name
Are you any Existing Patient at Harvard Street Neighborhood Health Center
*
Please Select
YES
NO
Date of Birth
*
-
Month
-
Day
Year
Date
Legal Sex
*
Female
Male
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Primary Insurance Information
Insurance Plan Name
Insurance ID
Additional Information
Primary/Preferred Language
*
Race
*
Please Select
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian
Pacific Islander
White
Other
Ethnicity
*
Please Select
Latin American/Latin, Latino
Hispanic or Latino/Spanish
Not Hispanic or Latino
Agricultural worker
*
Yes
No
Declined to Answer
Homeless status
*
Yes
No
Declined to Answer
In Public Health Housing
*
Yes
No
Declined to Answer
I hereby declare that all the given information are accurate.
*
I agree
Submit
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