COVID - 19 Vaccination Request Form
Please complete this form to obtain a COVID-19 Vaccination Appointment via NewYork-Presbyterian, at the Armory located at 651 West 168th Street. ***You must be 65+ and you must be a New York City resident of Harlem, Washington Heights, Inwood or the Bronx.***
If you are not 65+ years of age and/or not a New York City resident of Harlem, Washington Heights, Inwood or the Bronx, please do not complete this form.
First Name *
Last Name *
Phone Number *
Email Address (if available)
Home Street Address (Include Apartment Number) *
Home City *
Home State *
Home Zip Code *
Date of Birth *
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Have you been previously tested for COVID-19?
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