Skip to content
Home
About Us
Services
For Patients
Patient Portal
Patient Forms
Insurance Info
Frequently Asked Questions
Contact Us
Menu
Home
About Us
Services
For Patients
Patient Portal
Patient Forms
Insurance Info
Frequently Asked Questions
Contact Us
COVID-19 Vaccine Waiting List Application
Please enable JavaScript in your browser to complete this form.
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
