COVID-19 Vaccine Request Form

Please fill out the form below to request the COVID-19 vaccine.

First Name

Last Name

Date of Birth

Phone Number

Is this a good number to text?

Yes, it is.

No.

If possible, please provide a phone number that we can text.

Please select a location.

- Select -Clovis Health Center (2497 East Herndon Avenue, Suite 103)Corcoran Health Center (1000 Chittenden Avenue)Dinuba Health Center (300 Westgate Way)Earlimart Health Center (476 East Washington Avenue)Fowler Health Center (106 East Main Street)Fresno-Blackstone Health Center (1110 North Blackstone Avenue)Fresno-Bullard Health Center (1780 East Bullard Ave)Fresno-Shields Health Center (1901 East Shields Avenue, Suite 130)Fresno-Milburn Health Center (6810 North Milburn Avenue)Fresno-Tuolumne Health Center (2610 & 2630 Tuolumne Street)Huron Health Center (17008 13th Street)Kerman Health Center (517 South Madera Avenue)Lemoore Health Center (250 East Hanford Armona Road)Mendota Health Center (121 Barboza Street)Orange Cove Health Center (445 11th Street)Parlier Health Center (429 E. Manning Avenue)Reedley Health Center (1790 E. Manning Avenue)Sanger-7th Health Center (1570 7th Street)Sanger-Jensen Health Center (2502 Jensen Ave) Selma-Highland Health Center (2705 South Highland Ave)Selma-Rose Health Center (1201 Rose Ave)At a COVID-19 Vaccine EventI am not sure.

What is the preferred day of the week of your desired appointment?

- Select -MondayTuesdayWednesday ThursdayFridaySaturday

Email

How did you hear about United Health Centers?

Social Media

Looking through the Website

A Flyer

TV

Radio

Other

If other, please briefly explain.

We are growing! Find out about new health centers near you and much more?

That would be nice, thank you.

No, thank you.

United Health Centers will contact you to schedule your appointment time and date.

Yes, I understand, and I would like to continue.

Submit Request >

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