COVID-19 Vaccine Registration Form

2260 Kennedy Blvd, Jersey City NJ 07306
+1 201-432-5205
+1 201-432-2578

COVID-19 Vaccine Registration

Vaccine Appointment Information

State *

Pharmacy Name *

Vaccination Rollout Category*

Are you Healthcare Worker?

Date of Birth (MMDDYYYY) *

Date *

Personal information

Have you taken your COVID first dose?

Patient's First Name *

Patient's Middle Name

Patient's Last Name *

Patient's Email *

Patient's Phone Number *

Gender *

Race *

Ethnicity *

Address Line1*

Address Line2 (Apt/Unit/Suite)

City *

State *

Zip Code *

Address Type *

Insurance And Identification Information

Note: You can upload maximum 4 images and please upload valid JPG, JPEG or PNG image format with recommended dimension 900X675

Type of Identification *

Document number (Enter document number)*

Do you have insurance?

At Hudson Pharmacy, we strive to offer the best possible quality services and products for all our customers as well as improve our dedicated work to the specific needs of our customers.

Contact

2260 Kennedy Blvd, Jersey City NJ 07306

View Map

Tel: 201-432-5205
Fax: 201-432-2578
Email: hudsonuno@yahoo.com

Business Hours

Mon – Fri: 10:00 AM – 7:00 PM
Sat: 10:00 AM – 5:00 PM
Sun: Closed