Bergen New Bridge Medical Center Vaccination Registration Form

Bergen New Bridge Medical Center Vaccine REGISTRATION FORM

Please complete the following form to register and chose SUBMIT to schedule a vaccine. The sections with asterisks (*) are required for Scheduling and Registration purposes. Address: 230 East Ridgewood Avenue, Paramus Drive Thru Location
The Flu vaccine is available for ages 6 months and up and the Hi-dose Flu vaccine is available for ages 65 and up only. The Covid vaccine is available for 5 years and up.

Moderna 2025-2026 (25 mcg/0.25mL) is available for ages 5-11 years.

Spikevax (Moderna) (50 mcg/0.5mL) is available for ages 12 and older.

mNEXSPIKE (Moderna) (10 mcg/0.2 mL) for 65 years and older.

Flucelvax (.5mL) is available for ages 6 months and older.

Fluad 65+ (.5 mL) is available for ages 65 years and older.
If you DO NOT have insurance free vaccines for FLU only will be available on 9/17. Covid Vaccines are by insurance only. Please make an appointment for 9/17 if you do not have insurance. If you do have insurance pick any date available. Thank you!
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.
Patient Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Your Age:*
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Address:*
City:*
State:*
Zip Code:*
Race:*
Ethnicity: *
Sex:*
If you chose 'Not Listed' please specify:
Gender Identity:*
If you chose 'Not Listed' please specify:
Sexual Orientation: *
If you chose 'Other' please specify:
Preferred Pronouns:*
If you chose 'Not Listed' please specify:
Marital Status
Preferred Language:
Ex. English, Spanish
Preferred Calling Name: (The name you like to be called)
Ex. Joe instead of Joseph
Religious Preference:
Optional
Advance Directive (Living Will):*

YesNoPrefer Not to Disclose
Choose your vaccine below. (Choose Flu and Covid if you wish to receive both vaccines) The Flu vaccine is available for 6 months and up with Hi Dose Flu available for 65 years and older. The Covid Vaccine is available for ages 5 and up.*

Covid 25-26 VaccineFlu 25-26 Vaccine
Are you a CarePlus Employee?*

YesNo
Do you have Insurance?*

YesNo
You selected No Insurance. If you DO NOT have insurance free FLU vaccines will be available on 9/17. Please make an appointment for 9/17 only if you do not have insurance. This is for FLU vaccines only Covid vaccine are only through insurance at this time. Thank you!
Health Insurance Information
Insurance Name:*
Member ID #:
Group #:
Policy Holder Name:*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Relationship to Patient:
Please provide a copy of the patient's insurance card (front and back) and photo ID: FRONT OF INSURANCE CARD UPLOAD HERE*

Cancelof
BACK OF INSURANCE CARD UPLOAD HERE*

Cancelof
PHOTO ID UPLOAD HERE (ex. License or other Government ID) *

Cancelof
Click Submit below to choose an appointment date and time.
Should be Empty:

Bergen New Bridge Medical Center Vaccine REGISTRATION FORM

Health Insurance Information