Hetrick Martin Institute Vaccination Site
2 Astor Pl, New York, NY 10003

Saturday, May 22, 2021
10:00AM - 5:00PM
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Email *
First Name (Legal) *
Last Name (Legal) *
First Name (Preferred/Chosen) *
Pronouns *
Sex (as it appears on your identity documents) *
Gender Identity (check all that apply)
Do you identify as a person of transgender experience
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Home Address 1 (if not applicable, type 2 Astor Place) *
Address 2
City *
State *
Zip (if using HMI, type 10003) *
Home Phone (type N/A if not applicable) *
Mobile Phone (type N/A if not applicable) *
Email (please re-enter) *
Race / Ethnicity (check all that apply) *
Health Insurance (optional):
Health Insurance ID Number (optional):
Consent to Share Info with Vaccine Provider: *
Consent to get the vaccine: *
Consent to be contacted by text: *
Consent to be contacted by email: *
Appt Date: 5/22/2021
Note:  You will be receiving the Pfizer vaccine, which requires two doses.  You will need to return to this site on June 12th for your second dose.  You will receive an email with more details for scheduling your second dose.  
Appt Time (choose a time block between 10AM and 5PM): *
A copy of your responses will be emailed to the address you provided.
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