Emerson Vaccine Clinic with Bergen New Bridge Medical Center 2024

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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* Personal Information

Name *

Company

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Mobile Number *

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* What is your preferred calling name/nickname?

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* Date of Birth - MM/DD/YYYY

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* 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

Not specified above, please specify

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* What is your sexual orientation?

Bisexual

Heterosexual or straight

Lesbian, Gay or Homosexual

Prefer not to disclose

None of the above, please specify

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* What is your gender pronoun?

She/her/hers

He/him/his

They/them/theirs

Other (please specify)

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* Do you have insurance?

Yes