Noble County - OHIO COVID-19 Vaccine Registration Form 65 & Over
Complete this form to register for a COVID-19 Vaccine. To register you MUST be 65 years old or older or have early childhood medical conditions that are carried into adulthood per Ohio’s Phase 1B guidance. Priority is given to those who live in Noble County, OHIO.

By completing this form your general information will be submitted to the Scheduling Call Center. At a later date and time the Call Center will contact you by the phone number provided and ask for additional information. This call back will not occur on the same day you submit the form. During this call you will be assigned a time and location. - You will not be able to request specific times and dates. Completing this form does not guarantee that you will be able to receive a vaccine, this is a screening process to get a list of eligible people. Scheduling is prioritized by age, governor's orders and vaccine availability. This survey may be closed after all of our registration spots are filled.

PLEASE DO NOT CALL TO ASK IF YOU WERE SCHEDULED. THE SCHEDULING CALL CENTER WILL CALL YOU.
Please answer all your calls, what you assume may be a tele-marketing call could be the Call Center trying to contact you.

People who are unable or uncomfortable with using online registration can still contact our Central Scheduling System at 1-866-395-1588.
First Name *
Last Name *
Date of Birth *
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Age *
Phone Number (no dashes please, just numbers) *
Email *
Street Address *
City *
County of Residence *
Medicare Beneficiary Number
Submit
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