COVID-19 Vaccine Pre-Registration

We are now scheduling COVID-19 vaccination appointments.

Please complete the form below and we will be in touch to schedule your COVID-19 vaccine appointment.

By completing this form, you are agreeing that NATIVE HEALTH may send you a registration request at the email address you provide on this form, that you understand that NATIVE HEALTH cannot guarantee the security of the messages it sends and that there is a risk the message may be intercepted and read by a third party.

Name / Nombre*
First Last
Address / Dirección*
Street Address Address Line 2 City State ZIP Code
Phone / Teléfono*
Email / Correo electrónico*
¿Prefiere ser contactado/a por alguien que hable español?*
- Sí
- No
Birthdate (MM/DD/YYYY)*
Age / Edad*
Gender / Sexo*
- Female
- Male
- Decline to Specify
- Other
Race / Raza*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Pacific Islander
- White
- Unknown or Not Reported
Ethnicity / Etnicidad*
- Hispanic or Latino
- Not Hispanic or Latino
- Unknown / Not Reported
Location of vaccine clinic:*
Preferred times:*
- 8am - 10am
- 10am - Noon
- Noon - 1pm
Preferred times:*
- 10am - Noon
- Noon - 2pm
- 2pm - 4pm
- 4pm - 6pm
Insurance:*
- Private Insurance
- AHCCCS
- No Insurance
Carrier Name
I am a registered patient/client in Medical, Dental, Behavioral Health/or other program*
- Yes
- No
OR
I am a client in*
- Health Start
- Home Visiting
- WIC
- LAUNCH
- Arizona Long Term Care System
- Community Garden
- Senior Food Box Program
- Diabetes Program
- Tribal Practices
- Youth Resiliency
- Native STAND
- NONE or N/A
Tribal Affiliation / Afiliación tribal*
- Yes
- No
Which Tribe?
Is this your first dose of COVID Vaccine?*
- Yes
- No

COVID-19 Vaccine Pre-Registration

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