Monroe County Dental Professionals Covid Vaccine Distribution Information Sign-up January 2021

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 

The actual distribution of the vaccine will be coordinated by the Monroe County Public Health Department. 

Primary Dentist State of Michigan Licensing Information

List primary dentist full name for State of Michigan Dental License.
City where primary dentist, above, State of Michigan Dental license, is registered. If unknow list city for place of work/ home.

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.
Phone number format (xxx) xxx-xxxx

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. 
Type numerical digit number of total staff that you plan to sign-up for the vaccine, including the primary dentist and contact person if applicable.
Vaccine Distribution Guidelines Confirmation • Acknowledgment that the vaccine at this delivery is for your dental professionals who directly contact patients and are at high risk for Covid-19 virus transmission. Dentists, hygienists, dental assistants are in this category. The sign-up is not for receptionists, billers, or janitors, who do not directly have contact with Covid-19. Dental professionals will use their professional judgment in making this determination for their team.

Enter any questions you may have for the Monroe County Public Health Department on vaccine distribution. If more space is needed email