Hep B Community Clinic Registration Form

Hepatitis B Community Clinic

Please check back for the most updated clinic schedule. For more information or questions, please contact VACF at 714.751.5805 or b-freeoc@vacf.org.
To select your preferred language, please click English on the upper right corner and select your preferred language from the drop-down list.

Để chọn ngôn ngữ quý vị muốn, vui lòng nhấp vào English ở góc trên bên phải và chọn ngôn ngữ từ danh sách.

若要選擇您偏好的語言，請點擊右上角，然後從下拉式選單中選取您想要的語言 Chinese)

원하시는 언어를 선택하시려면, 오른쪽 상단의 English를 클릭하신 후, 나타나는 드롭다운 목록에서 원하는 언어를 선택해 주세요.

ដើម្បីជ្រើសរើសភាសាដែលអ្នកចូលចិត្ត សូមចុចភាសាអង់គ្លេសនៅកន្លែងខាងលើស្ដាំ ហើយជ្រើសរើសភាសាដែលអ្នកចូលចិត្តពីបញ្ជីខាងក្រេាម
Language Used to View Form
Available Clinic Dates:

VPASC Health Fair, 10/26/2025, 9AM - 2 PM at Freedom Hall, 16801 Euclid St, Fountain Valley, CA 92708 (screening and consultation only)
Your Contact Information
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number*
E-mail
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Services You Would Like to Receive:

Hepatitis B screeningHepatitis B vaccination - dose 1Hepatitis B vaccination - dose 2Hepatitis B vaccination - dose 3Hepatitis B vaccination - boosterConsultation with a doctor
Vaccination service is not available at the 10/26/2025 clinic.
Please upload your file that you would like to share to help us prepare for your appointment (Example: screening results, lab test, etc.).

Cancelof
Do you have health insurance? (Your insurance status does NOT disqualify you for services.)

YesNo
Health Insurance - Member ID
Health Insurance - Group Number
Health Insurance - RxBIN
Health Insurance - RxPCN
Did anyone help you to complete this form?*

YesNo
Please provide the name of the person/organization that helped you:
Comments or Questions:
Check the box below before submitting:*

I understand that by sharing my contact information, I agree to be contacted by the B-Free OC program team. My information will stay private and will never be sold or shared with outside parties.
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Hepatitis B Community Clinic