COVID-19 Vaccination Registration
Thank you for choosing to receive your COVID-19 Vaccination through ONU Healthwise. Please complete this form to the best of your ability so that we can ensure we adhere to the guidelines set in place by the Ohio Department of Health. After pre-registering, you will receive a phone call from a pharmacy staff member to schedule an appointment when vaccine is in stock and you are eligible to receive it.
Date of Birth
How do you prefer we contact you to schedule an appointment?
Do you have any chronic health conditions? Examples include heart disease, asthma or COPD, diabetes, autoimmune diseases, or heart failure.
Please select the criteria below that best describes you. If you are not part of phase 1a, please select "none of these options apply to me" and click next. You will then be given the option to select from a list of phase 1b criteria.
Please select which group best describes you
Assisted Living Facility - Resident
Assisted Living Facility - Staff
Skilled Nursing Facility (RCF) - Resident
Skilled Nursing Facility (RCF) - Staff
State of Ohio Dept. of Dev. Disabilities (DODD) - Resident
State of Ohio Dept. of Dev. Disabilities (DODD) - Staff
State of Ohio Veterans Home - Resident
State of Ohio Veterans Home - Staff
State of Ohio Mental Health and Addiction Services (MHAS) - Resident
State of Ohio Mental Health and Addiction Services (MHAS) - Staff
State of Ohio Dept. of Rehabilitation & Correction - LTC Resident
State of Ohio Dept. of Rehabilitation & Correction - LTC Staff
Congregate Care Facility - Resident
Congregate Care Facility - Staff
Hospital Worker - Clinical Staff
Hospital Worker - Administrative Staff
Hospital Worker - Ancillary Staff
Non-Hospital Healthcare Worker - Clinical Staff
Non-Hospital Healthcare Worker - Administrative Staff
Non-Hospital Healthcare Worker - Ancillary Staff
Emergency Medical Services (EMTs/Paramedics)
None of these options apply to me
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