PHASE 1A - Healthcare Practice Vaccination Request

A "Phase 1A Healthcare Practice" is defined as a professionally managed setting that is engaged in the delivery of healthcare services by paid and/or unpaid persons who have the potential for direct or indirect exposure to patients or infectious materials. This form is not intended for Long-Term Care facilities.

View the MDHHS Prioritization Guidance to determine eligibility

This request is for practices located in Wayne County, not including Detroit. Practices located in the city of Detroit should contact the Detroit Health Department at 313-230-0505.

Before submitting this form, please poll all employees to determine how many are actually being vaccinated. Once the form is submitted, you will be contacted by a health department representative for scheduling. Due to request volume, please allow up to three (3) business days to be contacted.

Once scheduled, download and print a copy of this registration form for each person getting vaccinated and have them bring the completed form with them: Vaccine Registration Form