STAY-AT-HOME - Enroll Form

How did you hear about this program? {{trnslng.queslabel_HowdiduHear}}

NYC Health + Hospitals {{trnslng.queslabel_HowdiduHearNYCHH}}

Other {{trnslng.queslabel_HowdiduHearOther}}

Where did you last receive medical care? {{trnslng.queslabel_medicalcare}}

First Name * {{trnslng.queslabel_firstname}} *

Last Name * {{trnslng.queslabel_lastname}} *

Date of Birth * {{trnslng.queslabel_dob}} *

Sex assigned at birth * {{trnslng.queslabel_sexatbirth}} *

† We ask for this information because it can help us take better care for you. {{trnslng.smalllabel_sexatbirth}}

Gender Identity (please select all that apply) {{trnslng.queslabel_gender}}

ZIP code where you live * {{trnslng.queslabel_zipcode}} *

Mobile Phone Number * {{trnslng.queslabel_mobnumber}} *

Mobile phone number (confirmation) * {{trnslng.queslabel_mobileconfirm}} *

I confirm that I can receive text messages at this phone number. {{trnslng.queslabel_mobileconfirmYes}}

Emergency Contact - First Name Last Name {{trnslng.queslabel_emergencyname}}

Emergency Contact - Phone number {{trnslng.queslabel_emergencyphone}}

Symptom Duration (Roughly when did you start feeling sick?) * {{trnslng.queslabel_symptomduration}} *

What symptoms do you have today that you do not normally have? * {{trnslng.queslabel_symptoms}} *

Please check ALL of the medical conditions that apply to you below * {{trnslng.queslabel_medproblems}} *

Consent Statement * {{trnslng.queslabel_consentstmt}} *

By clicking “I consent”, I consent to participate in the Stay-At-Home Symptom Monitoring Program (the “Program”).
As part of the Program, I consent to receive text messages to the mobile phone number I have listed above.
I understand that my responses to these text messages may contain protected health information and that text messages may not be secure transmissions.
I understand that standard text message rates may apply.
I understand that Program medical staff may call me on the mobile number I have provided to discuss my symptoms.
I agree to allow the clinical staff to call the emergency contact listed above if I cannot be reached.
I understand that I may opt out of the Program at any time.
I understand that at any point, if I feel that my symptoms are too severe to tolerate at home, I can go to the emergency room or call 911. {{trnslng.label_consentstmtBlock}}

I consent {{trnslng.label_Iconsent}}

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