Sandusky County Phase 1B Pre-Registration

Sandusky County COVID-19 Vaccine Pre-Registration

If you are in Phase 1B, please complete the form below to pre-register for COVID-19 vaccination in Sandusky County, Ohio. This is ONLY a pre-registration. This is NOT a guarantee of an appointment to receive a COVID-19 vaccine.

Phase 1B:

People aged 65 and older

People living with severe congenital, developmental, or early-onset medical conditions

Adults who work in schools (K-12)

Please complete this form for each individual person that needs pre-registered for the vaccine. There is no charge to the patient for the vaccine.

If you work for a school located in Sandusky County, please wait to hear from your Superintendent about how to register for the COVID-19 Vaccine. DO NOT COMPLETE THIS FORM.

Sandusky County Public Health is not responsible for any information entered incorrectly into this form. Please double check to make sure all information has been entered correctly. Sandusky County Public Health, The Bellevue Hospital, or ProMedica Memorial Hospital will be contacting individuals by phone to schedule their appointment.

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* 1. Which of the following describes the person to be vaccinated? Select all that apply.

Individual 65-69 years old.

Individual 70-74 years old.

Individual 75-79 years old.

Individual 80+ years old.

Individual has a severe congenital, developmental, or early-onset medical disorders that make them particularly vulnerable. This could include cerebral palsy; spina bifida; congenital heart disease; type 1 diabetes; inherited metabolic disorders; severe neurological disorders including epilepsy; severe genetic disorders including Down Syndrome, Fragile X, Prader Willi Syndrome, and Turner Syndrome; severe lung disease including cystic fibrosis and severe asthma; sickle cell anemia; and alpha and beta thalassemia.

None of the above

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* 2. First and last name of the individual being vaccinated.

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* 3. What is the name of the person who will be scheduling the appointment for the individual being vaccinated? If you are scheduling for yourself, please enter "self" into the comment box.

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* 4. What is the best phone number to call to schedule the appointment? Area code must be included. Please use format (555-555-5555). Double-check the phone number to make sure it is correct.

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* 5. Email address of the person scheduling the vaccine. If no email please enter NA into the comment box.

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* 6. Birthdate of the person being vaccinated. Please provide month, day, and year.

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* 7. Please provide contact information for individual to be vaccinated. If the individual being vaccinated does not have an email address or phone number, please enter NA into that comment box.

Address

City/Town

State/Province

ZIP/Postal Code

County

Email Address

Phone Number

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* 8. Which is your preferred vaccination location? This does not guarantee that you will be scheduled at your preferred location nor does it guarantee an appointment for vaccination.

Sandusky County Public Health
2000 Countryside Drive
Fremont, OH 43420

Promedica Memorial Hospital
715 S. Taft Avenue
Fremont, OH 43420

Bellevue Hospital
1400 W. Main Street
Bellevue, OH 44811

Community Health Services
2221 Hayes Avenue
Fremont, OH 43420

No preferred location

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* 9. I have double checked the information I entered into this form and agree that it is correct. I understand that any information that has not been entered correctly may result in SCPH not being able schedule the COVID-19 Vaccination. I know that Sandusky County Public Health is not responsible for any information that was not entered correctly.

I also understand that completing this form is only a pre-registration and does not guarantee an appointment to receive a COVID-19 Vaccination. Please be patient. Wait times may be lengthy. We will be contacting you to schedule an appointment based on Phase 1B implementation and the availability of COVID-19 Vaccines. All vaccination distribution is subject to availability of doses provided by the State of Ohio to SCPH.

Sandusky County Public Health will be coordinating the COVID-19 Vaccination schedule with Bellevue Hospital, Promedica Memorial Hospital, and SCPH for Phase 1B. You may be contacted by 1 of these agencies for COVID-19 vaccination scheduling.

I agree