Please only complete the form below if you are age 65 or older or have one of the listed qualifying medical conditions.

Once Huron County Public Health (Ohio) begins this vaccination phase, we will contact each individual to schedule an appointment. Please check your contact information for accuracy before submitting.

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* First name of individual to be vaccinated

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* Last name of individual to be vaccinated

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* Age of individual to be vaccinated

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* Does the individual to be vaccinated have one or more of the following medical conditions? Eligible Medical Conditions include: Cerebral palsy; spina bifida; congenital heart disease; type 1 diabetes; inherited metabolic disorders; severe neurologic disorders including epilepsy; severe genetic disorders including Down Syndrome, Fragile X, Prader Willi Syndrome, Turner Syndrome; severe lung disease including cystic fibrosis and severe asthma; sickle cell anemia; or alpha- and beta-thalassemia.

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* Phone Number

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* Email Address

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