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2260 Kennedy Blvd, Jersey City NJ 07306
+1 201-432-5205
+1 201-432-2578
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COVID-19 Vaccine Registration
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Step
1
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Vaccine Appointment Information
State
*
New Jersey
New Jersey
Pharmacy Name
*
Hudson Pharmacy, 2260 Kennedy Blvd, Jersey City NJ 07306
Vaccination Rollout Category
*
PHASE 1A
Long-term care facility residents
Health care personnel
Potentially exposed to infectious material that can transmit disease
Persons ages 65 and older
Persons ages 16-64 with high-risk conditions as identified by the CDC
Law enforcement
Firefighters
Grocery store employees
Food/agriculture workers
PHASE 1B
People in congregate settings not otherwise specified as long-term care facilities, and persons receiving home and community-based services
First responders
Correctional officers and other workers serving people in congregate care settings not included in Phase 1A
Food and agricultural workers
U.S. Postal Service workers
Manufacturing workers
Grocery store workers
Education workers
Clergy and other essential support for houses of worship
Public transit workers
Individuals caring for children or adults in early childhood and adult day programs
PHASE 1C – Essential workers in these sectors
Transportation and logistics
Water and wastewater
Food service
Housing construction
Finance, including bank tellers
Information technology
Communications
Energy, including nuclear reactors
Legal services
Federal, state, county and local government workers, including county election workers, elected officials and members of the judiciary and their staff
Media
Public safety
Public health workers
PHASE 2
All individuals not previously covered who are 16 and older and do not have a contraindication to the vaccine
Are you Healthcare Worker?
*
No
Yes
Date of Birth (YYYYMMDD)
*
Date / Time of Appointment
*
Date
Time
Next
Personal information
Patient's Name
*
First
Middle
Last
Patient's Email
*
Patient's Phone
*
Gender
*
Select Gender
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Female
Unknown
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Race
*
Select a Race
American Indian or Alaska Native
Asian
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Native Hawaiian or other Pacific Islander
White
Other Race
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Ethnicity
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Hispanic or Latino
Not Hispanic
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Address
*
Address Line 1
Address Line 2
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Emergency Contact Name
*
Emergency Phone
*
Relationship with Person
*
Primary Care Doctor
Doctor's Phone
Doctor's Address
Address Line 1
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Alaska
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Insurance And Identification Information
Type of Identification
*
Select Type of Identification
SSN
Driver's License
State ID
Passport
Do you have insurance?
*
No
Yes
Insurance Detail Type
Enter Insurance Details Manually
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Pharmacy Insurance
Medical Insurance
Medicare Insurance
Are you the cardholder?
*
Yes
No
Insurance Image
*
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