COVID-19 Vaccine Planning Form [Washington County, Ohio]
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Email address *
One Submission Per Person
First Name
Last Name
Phone Number
Convenient locations to receive a vaccine (check ALL that apply)
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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.
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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.
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Do you live in Washington County, Ohio?
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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
A copy of your responses will be emailed to the address you provided.
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