Enrollment - Rutgers RWJ Your Health Kiosk

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Which language do you prefer?*

English
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This platform does not support the language you chose at this time, but we do have navigators that speak your language and can thus provide personalized chat services.

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Name:*

First Name: Last Name:

Mobile Number:*

Birth Date:*

Email:

Zip code:*

Race/Ethnicity:*

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American Indian/Alaska Native
Asian
Black/African American
Caucasian/White
Hispanic/Latino
Native Hawaiian/Pacific Islander
Southeast Asian
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What was your biological sex at birth?*

Male
Female
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What gender do you identify as?*

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Female
Binary
Transgender (male to female)
Transgender (female to male)
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Do you have a cellphone for your personal use?

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No

Do you currently smoke tobacco or have you smoked tobacco in the past?

I have never smoked
I currently smoke
I previously smoked

For how many years did you smoke?

How many packs a day do you smoke?

How many years ago did you quit?

For how many years did you smoke?

How many packs a day do you smoke?

Have any of your family members ever been diagnosed with cancer?*

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No

What kind of messages would you like to receive?*

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Cancer
Long Covid
Asthma
None
All
Other

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Is there anything specifically we can help you with?*

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No
Not at this time

Please explain*

Consent*

I have verbally completed the enrollment form and provide electronic consent to enroll. I grant permission to RWJBH and/or GoMo Health to contact my cell phone via text messages. As part of the Your Health Kiosk program, I will receive up to 3 text messages per week. This program is completely voluntary and I may opt out at any time by replying STOP. For assistance with the program, reply HELP. Message and data rates may apply depending on my mobile carrier plan.

Your Health Kiosk - A Neighborhood Health Connection

Enrollment Form