Monroe County Dental Professionals Covid Vaccine Distribution Information Sign-up
This form is for sign-up of dental professional to receive announcement of Covid-19 Vaccine Distribution for Monroe County and is being done in cooperation with the Monroe County Public Health Department. This form is being hosted by the Detroit District Dental Society that covers Monroe County. This initial sign-up is to streamline the information for the Monroe County Public Health Department to make vaccine distribution faster to dental professionals.
If you have questions on this form or process please contact Marcy Dwyer, Detroit District Dental Society at 313.337.4900 or firstname.lastname@example.org.
The actual distribution of the vaccine will be coordinated by the Monroe County Public Health Department.
Primary Dentist State of Michigan Licensing Information
Dental Office Primary Contact Person
Identify one main contact person for your dental team. That person will sign up all employees to receive the vaccine in Monroe County. The vaccine appointments will be coordinated by this person and they will receive the information for the vaccine distribution update. This sign-up link when sent to them should not be distributed to other organizations and only used by one person on your team.
Questions please submit below in a later section of this form.
The contact person can be an office manager, dentist, or other staff member.
List organization name, full address with zip code for workplace. If multiple locations please list all. If a dentist volunteers or does not have a work place list your home address.
Vaccine Distribution Preliminary Information
This information is to help in planning by the Monroe County Public Health Department. If the number of employees changes when you actually sign-up for the vaccine distribution that is permissible. The number to submit at this time is an estimate.
Note the vaccine distribution at this phase is for employees that are in high risk transmission of Covid-19 with direct contact to patients.
Enter any questions you may have for the Monroe County Public Health Department on vaccine distribution. If more space is needed email email@example.com