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MPV Vaccine Intake Form

Epicenter NYC is helping our community secure Monkeypox vaccine appointments for eligible individuals*. *The following people are eligible to be vaccinated in NYC: - People of any sexual orientation or gender identity who have or may have multiple or anonymous sex partners, or participate or may participate in group sex - People of any sexual orientation or gender identity whose sex partners are eligible per the criteria above - People who know or suspect they have been exposed to the MPV in the last 14 days - Anyone else who considers themselves to be at risk for MPV through sex or other intimate contact. NOTE: People who are breastfeeding or pregnant who are otherwise eligible for vaccination can get vaccinated. For more information, see the JYNNEOS FAQ. If you have had MPV, then you likely have some protection against another infection and are currently not eligible to get a first or second dose If you do not meet these criteria, please do not make an appointment as you are not eligible to be vaccinated at this time. Please continue to check nyc.gov/health/monkeypox for updates. PLEASE READ BEFORE SUBMISSION: I have asked Epicenter NYC and their volunteers to assist me with registering for a MPV vaccine appointment in New York State, including by taking the following steps on my behalf: a) collecting and submitting the personal information I have provided, such as my name, date of birth, and contact information; b) submitting my confirmation that I am eligible for the vaccine. I understand that I am providing this information to vaccine providers under penalty of perjury; that I am fully responsible for its accuracy and truthfulness; and that I will be expected to provide proof of identification and eligibility at my vaccination appointment. I understand and agree that Epicenter NYC is not responsible for verifying the accuracy of the information I have provided or my eligibility for the vaccine, and that I am solely responsible for what they submit on my behalf. Subscribe to our newsletter for more information and updates here: https://epicenter-nyc.com/subscribe/ If you have any questions, issues, or concerns please contact us at vaccine@epicenter-nyc.com Your registration screenshot/confirmation will be sent by email. Stay safe!

Street Address
  • {name}
Which race do you identify as?
  • Asian, including South Asian
  • Black, including African American or Afro-Caribbean
  • Native American or Alaska Native
  • Native Hawaiian or Pacific Islander
  • White
  • Prefer not to answer
  • Other
  • Unknown
*Do you identify as Hispanic, Latino or Latina?
What sex were you assigned at birth?
How do you identify your gender?
Which of the following best describes your sexual orientation? Please select the one that best describes you. Do you identify as:
Which specific ethnic or cultural groups do you identify as, if any?
Select all that apply
  • Arab
  • Chinese
  • Dominican
  • Guyanese
  • Haitian
  • Indian
  • Italian
  • Jamaican
  • Jewish
  • Mexican
  • Puerto Rican
  • Russian
  • Another Group or Groups
  • I do not identify as any specific ethic or cultural group
Do you have a disability?
The following is a list of some examples of disabilities, but it is not a full list: -You are deaf or have difficulty hearing -You are blind or you have difficulty seeing, even when wearing glasses -Because of a physical, mental, or emotional condition, you have difficulty concentrating, remembering, being in crowded places, interacting with people, or making decisions -Because of a physical, mental, or emotional condition, you have difficulty walking or climbing stairs, traveling, dressing, or bathing
Do you have health insurance?
Smallpox/Monkeypox vaccinations are free for you! Insurance is not required, but if you have insurance, the vaccine provider will bill your insurance company for an administration fee. You will not be charged a copayment.

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