TCNJ Flu Vaccine Clinic with Bergen New Bridge Medical Center 2024

Pre Visit Information

This questionnaire includes questions regarding Sexual Orientation and Gender Identity which we are required to ask all patients as per Joint Commission and the National Academy of Medicine. This data is used to provide equitable care to everyone and to treat every individual as a whole person, however if you prefer to not answer them, simply select the option Choose not to Disclose.

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* 1. Personal Information

Name *

Company

Address *

City/Town *

State/Province *

ZIP/Postal Code *

TCNJ Email Address *

Mobile Number *

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* 2. What is your preferred calling name/nickname?

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* 3. Date of Birth - MM/DD/YYYY

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* 4. What is your gender identity?

Female

Female to Male/transgender male

Male

Male to Female/transgender female

Neither exclusively male nor female

Choose not to Disclose

Other (please specify)

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* 5. What is your sexual orientation?

Bisexual

Heterosexual or straight

Lesbian, Gay or Homosexual

Choose not to Disclose

Other (please specify)

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* 6. What is your gender pronoun?

She/her/hers

He/him/his

they/them/theirs

Other (please specify)

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* 7. Primary Insurance Card

Please upload photo of insurance card.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 8. Back of Insurance Card

Please upload photo of back of insurance card.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 9. Insurance Card Information

Name of Insurance Plan

Policy

Group ID (N/A if not applicable)

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* 10. Photo ID

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 11. I consent to be given the Flu Vaccine by Bergen New Bridge Medical Center.

Yes