Healthcare Disparities Registration
Register to help us understand and address disparities in healthcare access and outcomes.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your gender?
*
Female
Male
Non-binary
Prefer not to say
Other
What is your race/ethnicity?
*
White
Black or African American
Hispanic or Latino
Asian
Native American or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
Do you currently have health insurance?
*
Yes
No
Prefer not to say
What barriers to healthcare have you experienced? (Select all that apply)
Cost of care
Lack of transportation
Language barriers
Lack of providers nearby
Cultural differences
Lack of insurance
Other
Preferred language for healthcare services
Please Select
English
Spanish
Chinese
Vietnamese
Tagalog
Other
Register
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