Pre-Registration for COVID-19 Vaccination

WE ARE COMMITTED TO YOUR HEALTH, AND WANT TO OFFER YOU THE COVID-19 VACCINE AS SOON AS POSSIBLE. UNFORTUNATELY, WE DON’T HAVE SUFFICIENT DOSES TO PERMIT EVERY ELIGIBLE PATIENT TO RECEIVE THE VACCINE AS QUICKLY AS WE HAD HOPED.

IN ORDER TO MAKE SURE WE HAVE YOUR INFORMATION FOR FUTURE VACCINATION OPPORTUNITIES, PLEASE FILL OUT THE FORM BELOW. WE WILL CONTACT YOU AS SOON AS WE HAVE A VACCINE TO ADMINISTER TO YOU.

FOR ADDITIONAL INFORMATION ON OTHER VACCINATION SITES, PLEASE VISIT THE OHIO DEPARTMENT OF HEALTH WEBSITE AT HTTPS://VACCINE.CORONAVIRUS.OHIO.GOV/

Pre-Registration Eligibility

People in Phase 1B as determined by the Ohio Department of Health (ODH) can now pre-register to receive a COVID-19 vaccine with The MetroHealth System.

Phase 1B is limited to people who:

Are age 65 and older
Are an employee of a K-12 school
**Have severe congenital, developmental or early-onset medical disorders such as: cerebral palsy; spinal bifida; congenital heart disease; type 1 diabetes; inherited metabolic disorders; severe neurologic disorders, including epilepsy; severe genetic disorders including Down syndrome, Fragile X, Prader-Willi Syndrome and Turner Syndrome; severe lung disease, including cystic fibrosis and severe asthma; sickle cell anemia; and alpha- and beta-thalassemia

If you are eligible, please pre-register to receive a COVID-19 vaccine by completing the form below.

1. Enter your contact information, choose how you would like to be contacted and submit the form.

2. When it is your time to schedule your vaccine appointment, based on ODH guidelines and vaccine availability, you will be contacted via the method you chose on the pre-registration form and be provided a special phone number to call to schedule your vaccine.

If you do not have an email, you can easily create one with Microsoft or Google.

You must be in one of the above groups and have a scheduled appointment with us to receive the COVID-19 vaccine.

* = required

Contact Information

1. Have you already received the first dose of the COVID-19 vaccine? *

YES

Legal First Name *

Legal Middle Initial

Legal Last Name *

Date of birth * +

Gender *

Male

Female

Address *

Address 2

City *

State *

Zip Code *

Preferred contact method *

Phone/Text

Cell/Mobile Phone *

Home Phone

Email address *

Is MetroHealth your primary provider of health care? *

Yes

Please enter your MetroHealth Medical Record Number (MRN), if possible.

Last 4 digits of Social Security Number (if MRN not available):

Do you provide hands on health or medical care to clients/patients? *

Yes

I am part of the following category (choose the first category you fall into): *

If other, please describe. *

0/200 characters

By clicking Submit, I certify that to the best of my knowledge and belief the information provided, including for scheduling prioritization, is complete and correct. I understand that this consent is subject to revocation by me at any time except to the extent The MetroHealth System has already acted in reliance on this form.

The MetroHealth System is a nationally ranked non-profit, public health care system
located in Cleveland, Ohio, serving patients in Northeast Ohio.