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.

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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.

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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.

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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.

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