Vaccine Sign-up Form

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Community Health Fair

Get your COVID-19 shots, flu shots, health check-up, and more! Walk-ins are welcome!
SATURDAY, August 26, 2023

9:30 AM - 1:00 PM

Dieu Ngu Temple

14472 Chestnut St., Westminster, CA 92683

Free check-ups include:
- Blood pressure
- Blood Glucose
- Colorectal cancer
- Hepatitis B & C
- Consultation with a doctor
- COVID-19 & Flu shots
- Community resources
Please provide the information below.
Your Contact Information:*

PrefixFirst NameMiddle NameLast Name
Cell Phone Number
Home Phone Number
Date of Birth

MonthDayYear
Date
E-mail
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Information About Your Household*
Select Your Appointment for Food Pick-Up*
One appointment per family for food pick-up. Valid photo ID is required upon check-in.
Type of health screenings (no cost) you would like to receive:

Hepatitis B & C (Blood draw, no fasting needed)Tuberculosis (Blood Draw, no fasting needed)Colorectal cancer (FIT Kit)
You would like to get:

Flu shotCOVID-19 shotColorectal cancer screeningHepatitis B & C screening
You're are getting your:

First COVID-19 shotSecond COVID-19 shotCOVID-19 updated vaccine (bivalent)
Type of vaccine you'd like to get:

PfizerModernaAny
Do you have health insurance (for COVID-19 & flu vaccine)?

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

YesNo
If answered "Yes" in the question above, please provide the name the person/organization that helped you:
Comments or Questions:
For more information or questions, please contact VACF at 714.751.5805 or info@vacf.org
Should be Empty:

Community Health Fair