COVID-19 vaccine resources and consent form
Bay Area Community Health is now offering COVID-19 vaccines to patients and community members 65 and older or those who follow county guidelines listed below. If you do not meet the listed requirements, please do not contact BACH or fill out these forms. You will be able to register for a vaccine on a future date. Look for more information soon.
- Alameda County appointments are only available to people who live or work in Alameda County.
-
Santa Clara County appointments are only available to people who live in Santa Clara County.
― Healthcare workers who work in Santa Clara County are also currently eligible
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Appointments are currently open to the following persons ONLY:
― Healthcare Workers
― People ages 65+
― Food and Agriculture Workers
― Emergency Services workers
― Education/Childcare workers
- Click on the box to the county below to select an appointment time and register on line. Complete as much requested information as possible.
- Fill out below registration/screening/consent form and self-attestation form and bring with you to vaccine appointment
- Provide government-issued ID if you have it (ID is not required to get the vaccine)
- Bring an insurance card (if you have insurance) on the day of your visit
- Vaccination is drive-thru
- Please wear a short-sleeved or sleeveless shirt for the vaccine, OK to wear additional sweaters or jackets
- Be prepared to stay 15-30 minutes after the vaccine for observation of possible side effects
- Do not book appointment if you not in the eligible categories above. Due to our capacity, we are not able to accommodate others at this time.
Vaccine/Registration/Screening Consent Form:
Download
Self-Declaration of Vaccine Eligibility (Attestation) Form
You will not be seen if the form is not filled out beforehand.
Schedule an appointment
Alameda County
510.770.8040
Santa Clara County
408.729.9700
Fremont, CA 94538
San Jose, CA 95138
Vaccine Resources
For further info call: 510.770.8040
For appointment cancellation, please call: Alameda County: 510.252.6888
For appointment cancellation, please call:
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