Drive Thru Flu Clinic - Sept 26, 2026

Drive Thru Flu Clinic - September 26, 2026

United Community Health Center
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If you need help registering, please call 520-407-5400 Ext. 7617
Note: This flu clinic is ONLY for registered United Community Health Center patients ages 19 and older. If you are not a patient, but would like to become a patient, please call 520-407-5600 option 1.

Filling out this form will register you for the drive-thru flu shot clinic at Continental Family Medical Center Clinic located at 1260 S Campbell Rd bldg #1 Green Valley, AZ 85614 on Saturday September 26, 2026 from 9AM-12PM.

Please fill out one form per patient and do not register a patient more than once as slots are limited.
What provider at UCHC does the patient normally see?
Patient Legal Name

Legal First NameLegal Middle NameLegal Last Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Age
*This Clinic is for patients 19 years or older. You may call any of our clinics to schedule an in-office flu appointment for your child. Thank you.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
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Advanced Beneficiary Notice

Required for patients 19 and older
NOTE: YOU NEED TO MAKE A CHOICE ABOUT RECEIVING THESE HEALTH CARE ITEMS OR SERVICES

We expect that your insurance company will not pay for the items(s) or service(s) that are described below. Your insurance company does not pay for all of your health care costs. Your insurance company only pays for particular items and services that meet with your company’s reimbursement criteria. The fact that your insurance may not pay for this service does not mean that you should not receive it. There may be good reason your doctor recommended it. Right now, in your case, your insurance may not pay for:
- Influenza:
  - Flublok 19-64 years $122.81
  - High Dose 65+ and older $149.36
- Immunization Administration fee $61.38
The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully.

Ask us to explain if you do not understand why your insurance company may not pay. Ask us how much these items or service(s) will cost you.
Agree

YES, I want to receive these items or services I understand that my insurance company may not pay for this service. Please submit my claim to my insurance company. I understand that you may bill me for items or services and that I may have to pay the bill while my insurance is making its decision. If my insurance does pay, you will refund to me any payments I made to you that are due me. If my insurance company denies, I am fully responsible for payment in full. I understand that I can appeal to my insurance company.
Click here for more information on the flu vaccine

Get your annual flu shot to protect against this year's virus!
Select a time for your vaccine appointment
You are scheduling an appointment for Saturday September 26, 2026 at our Continental Family Medical Center Clinic located at:

1260 S Campbell Rd Green Valley, AZ 85614
Appointment

Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
If you are UCHC staff, filling this form out on behalf of a patient, click here. Otherwise, leave unchecked.
When you click the Submit button, you will be scheduling an appointment at our Continental Family Medical Center location located at 1260 S Campbell Rd in Green Valley. Please make sure this location, date and time works for you before submitting the form.

*This is a drive thru clinic please wear a short sleeved shirt.

Thank you!
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Drive Thru Flu Clinic - September 26, 2026

Advanced Beneficiary Notice

Select a time for your vaccine appointment