COVID-19 Vaccine Planning Form [Washington County, Ohio]
Asterisks (*) Indicate Required Fields
One Submission Per Person
Convenient locations to receive a vaccine (check ALL that apply)
Northern Washington County
Western Washington County
Newport/New Mat Area
less than 65 years old
I am a person with the following condition(s) that increase my risk of severe illness from the virus that causes COVID-19: Cancer, Chronic kidney disease, COPD (chronic obstructive pulmonary disease), Down Syndrome, Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies, Immunocompromised state (weakened immune system) from a solid organ transplant, Obesity, Pregnancy, Sickle cell disease, Smoking, Type 2 Diabetes Mellitus.
Share any other pertinent information. (i.e. I am a teacher, I am filling this out for my elderly parent, etc.) DO NOT submit Personal Health Information!
Please share my information with other vaccine providers.
Do you live in Washington County, Ohio?
This form is for Washington County, Ohio COVID vaccine planning/informational purposes ONLY and not a guarantee of services. The Ohio Department of Health call center can be reached at 1-833-4-ASK-ODH. It’s open seven days a week from 9 a.m. to 8 p.m. daily, including weekends. Call center staff includes licensed nurses and infectious disease experts. They are available to answer questions and provide accurate information about COVID-19, the risk to the public, and the state’s response. For more information on the State’s COVID-19 Vaccination Program, visit https://coronavirus.ohio.gov/wps/portal/gov/covid-19/covid-19-vaccination-program.
A copy of your responses will be emailed to the address you provided.
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