COVID-19 Vaccine Registration Form

COVID-19 Vaccine Registration Form

This record will be kept on file at the Warren City Health District. It acknowledges that the person has read and/or understands information about the Covid-19 vaccination and has seen or received a copy of the patient privacy act.

On the day you arrive you will need to fill out the consent form below and bring it with you.

Second Dose

After your first dose you must register for your second dose. If you are registering for the Second Dose, please remember to bring your immunization card with you.

Resources

What to know before, during, and after receiving a COVID-19 vaccine.
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Warren City
Health District

258 E. Market St
Warren, OH 44481
330-841-2596
John May, BA, Deputy Health Commissioner
PERSON TO BE VACCINATED: (Please use your legal name that is on your State ID or Birth Certificate, no nicknames.)
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PATIENT QUESTIONS

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INFORMATION ABOUT POPULATION AND/OR OCCUPATION

Please select the primary reason you are receiving the COVID-19 vaccine.

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Trumbull County
Combined Health District

176 Chestnut Ave NE
Warren, OH 44483
330-675-2489
Frank J. Migliozzi, MPH, REHS/RS, Health Commissioner
Warren City
Health District

258 E. Market St
Warren, OH 44481
330-841-2541
John May, BA, Deputy Health Commissioner
Copyright © 2021 City Of Warren, Ohio.