**This form is not for Covid vaccine appointments**
Please use this form if you are interested in pre-registering for a Covid vaccine appointment.
Please Take a Photo of the Front and Back of your Prescription Insurance Card (We will need the RX BIN, PCN, GRP, and ID.)
If you are unable to provide a photo of your insurance card, please provide the following:
Thanks for submitting your info! We will reach out to you shortly. Please expect a text message or call from us. If you have any questions, you can call/text us as 212-749-6626.