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DDDS_MonroeCountyPublicHealthCovidVaccineForm
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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 centraloffice@detroitdentalsociety.com.
The actual distribution of the vaccine will be coordinated by the Monroe County Public Health Department.
Primary Dentist State of Michigan Licensing Information
Dentist Full Name
Click to add
List primary dentist full name for State of Michigan Dental License.
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Primary Dentist City of State Dental License Registration
Click to add
City where primary dentist, above, State of Michigan Dental license, is registered. If unknow list city for place of work/ home.
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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.
Full name of Contact Person
Click to add
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Email of contact person
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Organization information
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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.
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Phone number of Contact Person
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Phone number format (xxx) xxx-xxxx
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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.
Number of dental professionals planning to receive the vaccine
Click to add
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.
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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.
I confirm I have read vaccine distribution guideline
Not confirmed read vaccine distribution guideline
Questions:
Click to add
Enter any questions you may have for the Monroe County Public Health Department on vaccine distribution. If more space is needed email centraloffice@detroitdentalsociety.com
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Member Center
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Board Vote September 2023 Motions
Evidence Based Dentistry
Finance Committee
Member Directory
My Member Profile
New Dentists
Renew My Membership
Staffing Your Practice
Volunteer Opportunities
Detroit District Dental Society Volunteer Form
Detroit District Community Volunteer Form
About
About DDDS
DDDS Executive Board/Staff
DDDS Committee
DDDS Past Presidents
DDDS Members MDA Committees/Other
Michigan Dental Licensing Information
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Calendar
News
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Survey_DDDS_Future_CE_Content
Future of Dentistry Evaluation and Website Links
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Dental Health FAQ
Free/Low Cost Dental Care
Dental Careers
Why Should I See a Dentist
What do Dentists do?
Oral Health Topics
Choosing Dental Insurance
Branches
Central
Leadership News
Upcoming Events
Eastern
Leadership News
Upcoming Events
Southwestern
Leadership News
Upcoming Events
Western
Leadership News
Upcoming Events
Branch Topic Survey
Sponsors
Associate Membership
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