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UCHC Covid-19 Vaccine Interest Form
Please complete the below information. One of our staff members will call you within two (2) business days to schedule your appointment.
Universal Community Health Center
1919 S. San Pedro St, Los Angeles 90011, Tel: 323-233-3100
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Mobile Phone Number (best number to text or call you)
*
Please enter a valid phone number.
Email
example@example.com
Which Vaccine are you interested in?
*
Please Select
Johnson and Johnson (1 dose)
Moderna (2 doses)
Pfizer (2 doses)
No Preference
Are you a Universal Community Health Center patient? If you are not a UCHC patient, please complete the two forms on the next page so that we can schedule your appointment.
*
Yes
No
Have you been seen as a patient at Universal Community Health Center in the past year? If you have not been seen as patient in the past year, please fill the two forms on the next page so that we can update your medical record.
*
Yes
No
Submit
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