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.
first Name *
Last Name *
Date of Birth *
MM
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DD
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YYYY
Phone Number *
Email
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.
Clear selection
Phase 1a
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 *
Next
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