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Home
About Us
Services
For Patients
Patient Portal
Patient Forms
Insurance Info
Sliding Fee Discount Program
Patient Education & Self-Management
Frequently Asked Questions
Contact Us
COVID-19 Vaccine Waiting List Application
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Are you between 50 to 64 years old?
*
Yes
No
Do you have any of the following chronic conditions?
*
Diabetes
Heart Disease
Kidney Disease
Respiratory Disease (Asthma, COPD)
High Blood Pressure
None of the above
Name
*
First
Middle
Last
Gender at Birth
*
Male
Female
Email
*
Race (Check all that apply)
*
Asian
Black/African American
White
Native Hawaiian
American Indian/Alaska Native
Pacific Islander
Ethnicity
*
Hispanic
Non-Hispanic
What type of insurance do you have?
*
Medicare
Medi-Cal
Medi-Medi (Dual-Eligible)
HMO
PPO
None/Self-Pay
Are you already a Nhan Hoa Patient?
*
Yes
No
Submit
