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. Have you previously received a COVID-19 vaccine dose? * Yes No What was your 1st dose vaccine type? * Pfizer Moderna Unicare 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 * First Middle Last Date of Birth * MM 1 2 3 4 5 6 7 8 9 10 11 12 / DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Age * choose your age group under 18 18-24 25-34 35-44 45-54 55-64 65-97 98+ Guardian Information If this patient is a minor, fill in the below section. Guardian Name * Phone # * Relationship to Patient: * Address * Address Line 1 City --- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Phone Number * Is this a cell phone number? * Yes No Would you like to have text messages enabled? * Yes No Standard messaging rates will apply. Email * Please enter your email address, so we can follow up with you. Sex * Female Male Ethnicity * --- Non-Latino/Non-Hispanic Latino/Hispanic Race * --- White Asian Black/African-American American Indian/Alaska Native Pacific Islander Native Hawaiian More Than One Race Refused To Report Sexual Orientation * --- Lesbian/Gay Straight Bisexual Something else Don't know Do not wish to disclose Gender Identity * --- Male Female Transgender Male Transgender Female Do not wish to disclose Other Are you an agricultural worker? * Yes No Are you a seasonal or migrant? * Seasonal Migrant Number of people in your family household: * --- 1 2 3 4 5 6 7 8 9 10 Annual Family Income: * Do you have Health Insurance? Choose "yes" if you have Medi-Cal. * Yes No With 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? * Yes No Choose 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. * Yes No 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 *
