Register if you would like to receive the COVID-19 Vaccination. Please enable JavaScript in your browser to complete this form. - Step 1 of 2Have you previously received a COVID-19 vaccine dose? *YesNoWhich vaccine are you interested in receiving? *Johnson & Johnson (Janssen)ModernaPfizerWhat was your 1st dose vaccine type? *PfizerModernaPlease enter the date of your 1st Moderna vaccine dose? *Please enter the date of your 1st Pfizer vaccine dose? *Name *FirstMiddleLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age *choose your age groupunder 18.18-2425-3435-4445-5455-6465-9798+Please note: Pfizer is available for those 12 years and older. Moderna and J&J are available for those 18 years and older. Address *Address Line 1City---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone Number *Is this a cell phone number? *YesNoWould you like to have text messages enabled? *YesNoStandard messaging rates will apply.Email *Please enter your email address, so we can follow up with you.Sex *FemaleMaleEthnicity *---Non-Latino/Non-HispanicLatino/HispanicRace *---WhiteAsianBlack/African-AmericanAmerican Indian/Alaska NativePacific IslanderNative HawaiianMore Than One RaceNext PageDo you have Health Insurance? Choose "yes" if you have Medi-Cal. *YesNoWho is your insurance carrier? i.e. Blue Shield, IEHP *Member ID #: *Have you been treated at one of the Unicare Community Health Center locations in the past 12 months? *YesNoChoose the location you were most recently treated at. *---Unicare-Pomona (1501 E. Holt Ave., Ste A, Pomona, CA 91767)Unicare-Los Angeles (2409 N. Broadway, Los Angeles, CA 90031)Unicare-Los Angeles (741 S. Alvarado St., Los Angeles, CA 90057)Unicare-Ontario (437 N. Euclid Ave., Ontario, CA 91762)Unicare-Ontario (1151 E. Walnut St., Ontario, CA 91761)Unicare-Colton (308 N. La Cadena Dr., Colton, CA 92324)Unicare-Fontana (16127 Foothill Blvd., Fontana, CA 92335)Unicare-Fontana (17500 Foothill Blvd. #A-2, Fontana, CA 92335)Unicare-San Bernardino (570 S. Mt. Vernon Ave., Ste. G, San Bernardino, CA 92410)Unicare-San Bernardino (184-190 E. Highland Ave., San Bernardino, CA 92404)Unicare-Riverside (5549 Van Buren Blvd., Riverside, CA 92503)Unicare-Corona (107 N. McKinley St., Corona, CA 92879107 N. McKinley St., Corona, CA 92879)Unicare-Moreno Valley (24853 Alessandro Blvd. #4, Moreno Valley, CA 92553)Are you interested in receiving information about Unicare’s services? Unicare offers medical, dental, optometry and behavioral health services. *YesNoAppointments are being made daily. Unicare has J&J, Moderna and Pfizer vaccines. Please select the location you would like to receive the vaccine at. Staff will call you within 1-2 business day to schedule your appointment. All appointments are given on a first come, first serve basis. Which location would you like to receive the Moderna vaccine at? *---Unicare-Riverside (5549 Van Buren Blvd., Riverside, CA 92503)Unicare-Corona (107 N. McKinley St., Corona, CA 92879107 N. McKinley St., Corona, CA 92879)Unicare-Moreno Valley (24853 Alessandro Blvd. #4, Moreno Valley, CA 92553)Unicare-Los Angeles (2409 N. Broadway, Los Angeles, CA 90031)Unicare-San Bernardino (570 S. Mt. Vernon Ave., Ste. G, San Bernardino, CA 92410)Unicare-Colton (308 N. La Cadena Dr., Colton, CA 92324)Unicare-Fontana (16127 Foothill Blvd., Fontana, CA 92335)Unicare-Ontario (437 N. Euclid Ave., Ontario, CA 91762)Unicare-Fontana (17500 Foothill Blvd. #A-2, Fontana, CA 92335)Unicare-San Bernardino (184-190 E. Highland Ave., San Bernardino, CA 92404)Unicare-Ontario (1151 E. Walnut St., Ontario, CA 91761)Unicare-Los Angeles (741 S. Alvarado St., Los Angeles, CA 90057)Unicare-Pomona (1501 E. Holt Ave., Ste A, Pomona, CA 91767)Which location would you like to receive the J&J vaccine at? *---Unicare-Colton (308 N. La Cadena Dr., Colton, CA 92324)Unicare-Fontana (16127 Foothill Blvd., Fontana, CA 92335)Unicare-Ontario (437 N. Euclid Ave., Ontario, CA 91762)Unicare-Fontana (17500 Foothill Blvd. #A-2, Fontana, CA 92335)Unicare-San Bernardino (184-190 E. Highland Ave., San Bernardino, CA 92404)Unicare-Ontario (1151 E. Walnut St., Ontario, CA 91761)Unicare-San Bernardino (570 S. Mt. Vernon Ave., Ste. G, San Bernardino, CA 92410)Which location would you like to receive the Pfizer vaccine at? *---Unicare-Los Angeles (2409 N. Broadway, Los Angeles, CA 90031)Unicare-Ontario (437 N. Euclid Ave., Ontario, CA 91762)Unicare-Los Angeles (741 S. Alvarado St., Los Angeles, CA 90057)Unicare-Pomona (1501 E. Holt Ave., Ste A, Pomona, CA 91767)Unicare-Fontana (16127 Foothill Blvd., Fontana, CA 92335)Unicare-Colton (308 N. La Cadena Dr., Colton, CA 92324)Unicare-Ontario (1151 E. Walnut St., Ontario, CA 91761)I HERE BY AUTHORIZE TREATMENT AT UNICARE COMMUNITY HEALTH CENTER: *ELECTRONIC SIGNATURE (Type full name) *By Signing your name you attest that you meet the requirements to receive a COVID-19 vaccination and all information submitted is accurate.DATE *Submit
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