Register if you would like to receive the COVID-19 Vaccination. We will contact you as soon as you are eligible to receive the vaccination. Please enable JavaScript in your browser to complete this form. - Step 1 of 2Have you previously received a COVID-19 vaccine dose? *YesNoWhat was your 1st dose vaccine type? *PfizerModernaUnicare Community Health Center has the Moderna vaccine. If you received Pfizer as your 1st dose, your second dose needs to also be Pfizer.Thank you for your interest in getting vaccination at our facility. However, because you have received Pfizer vaccine as your 1st dose, you must receive Pfizer as your second dose. Unicare Community Health Center currently only has the Moderna vaccine.Please enter the date of your 1st Moderna vaccine dose? *Name *FirstMiddleLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age *choose your age groupunder 1818-2425-3435-4445-5455-6465-9798+Guardian InformationIf this patient is a minor, fill in the below section.Guardian Name *Phone # *Relationship to Patient: *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/HispanicChoose the field which represents your current occupation *---Primary care healthDental careBehavioral healthHome health facilityTeacher/in class Emergency services (fire, police, first responders)ChildcareGrocery storeFood supply chain Postal serviceDelivery PharmacyNone of the aboveRace *---WhiteAsianBlack/African-AmericanAmerican Indian/Alaska NativePacific IslanderNative HawaiianMore Than One RaceRefused To ReportSexual Orientation *---Lesbian/GayStraightBisexualSomething elseDon't knowDo not wish to discloseGender Identity *---MaleFemaleTransgender MaleTransgender FemaleDo not wish to discloseOtherNext PageAre you an agricultural worker? *YesNoAre you a seasonal or migrant? *SeasonalMigrant Number of people in your family household: *---12345678910Annual Family Income: *Do you have Health Insurance? Choose "yes" if you have Medi-Cal. *YesNoWith what company are you insured? *Member ID #: *What is your Medi-Cal ID Number? *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. Please select the location you would like to receive the Moderna vaccine at. Staff will call you within 1 business day to schedule your appointment. All appointments are given on a first come, first serve basis. Appointment times cannot be changed. If you are late to your scheduled appointment, we will need to provide the dose to the next individual on the wait list.Which location would you like to receive the 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)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 *Previous PageSubmit
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