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.

Download BACH COVID-19
Vaccine/Registration/Screening Consent Form:

English | Spanish | Simplified Chinese

Download

Self-Declaration of Vaccine Eligibility (Attestation) Form

Alameda County | Santa Clara County

NOTICE: The consent and attestation form must be filled out before scheduling an appointment and coming to the clinic. 

You will not be seen if the form is not filled out beforehand.

Schedule an appointment

Slots fill up fast and new ones are added daily. If all slots are full, try checking again tomorrow.

Alameda County

510.770.8040

Santa Clara County

408.729.9700
39500 Liberty Street
Fremont, CA 94538
5504 Monterey Hwy
San Jose, CA 95138

Vaccine Resources

For further info call: 510.770.8040

For appointment cancellation, please call:
Alameda County: 510.252.6888