Please fill out this form to request an H1N1 vaccine appointment. Remember that if you are found to not be a member of a high risk group, we reserve the right to decline vaccinating you.
Name:
Date of Birth:
Select Location from the list: 1090 Amsterdam, 4th 1090 Amsterdam, 10th 425 West 59 St, 8th 425 West 59 St, 9th 374 West 125th St 1790 Broadway St Luke’s Hospital Roosevelt Hospital Other
Phone Number:
Email:
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