COVID-19 Vaccine Pre-Registration - Native Health of Phoenix

*Please note: this is a Pre-Registration Form. You will need to complete a COVID Vaccination Consent Form and Packet upon arrival.

Which Vaccine are you registering for?*

Adult Vaccine
Children 5 and Older Vaccine

Vaccine Clinic Event*

NATIVE HEALTH Central - 4041 N. Central Avenue, Building C, Phoenix (SE corner of Central/Indian School)
NATIVE HEALTH Mesa - 777 West Southern, Building B, Mesa (SW corner of Southern/Extension)

Name / Nombre*

First Last

Address / Dirección*

Street Address Address Line 2 City State ZIP Code

Phone / Teléfono*

Email / Correo electrónico*

Birthdate (MM/DD/YYYY)*

Age / Edad*

¿Prefiere ser contactado/a por alguien que hable español?*

Sí
No

Is this your first dose of COVID Vaccine?*

Yes
No

Which type of vaccine are you registering for?*

Pfizer
Moderna

Text communication*

NATIVE HEALTH often find it convenient to communicate by text messaging. Such communications may include, but are not limited to, appointment reminders, providing test results, information about available services and other notices related to NATIVE EALTH and the Vaccine Administration Management Systems (VAMS) as well as COVID vaccine reminders. Because text messaging is not secure methods of communication, there is some level of risk that text message could be read by a third party and NATIVE HEALTH cannot assure the confidentiality of information that it sends to you, or that you send to NATIVE HEALTH through text messaging. By signing this form, you are acknowledging these risks. You are not required to agree to accept such calls or messages from NATIVE AELTH as a condition of receiving services. I understand that NATIVE HEALTH's Notice of Privacy Practices is available to me online and I can access it at any time at this link.

Acknowledged