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.
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First Name
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Your answer
Last Name
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Your answer
Date of Birth
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Age
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Your answer
Phone Number (no dashes please, just numbers)
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Your answer
Email
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Your answer
Street Address
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Your answer
City
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Your answer
County of Residence
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Your answer
Medicare Beneficiary Number
Your answer
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