COVID-19 Vaccine "Save Your Spot" Form

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Thank you for your interest in receiving the COVID-19 vaccine. Please complete this brief form. We will contact you when you are eligible to receive the vaccine which is based on state/federal guidelines and available vaccine doses.

At that time, you will be given a link to make an appointment at one of our local vaccination sites. Proof of eligibility is required to be shown at the time of vaccination. For example, you can show work identification to support your essential worker status.

The Wellness Plan Medical Centers is pleased with your interest in the vaccine and we are hopeful that the supply of vaccine will increase in the next weeks to meet community demand.

Email *

Do you live or work in any of the following Counties? *

Wayne County

Oakland County

Macomb County

Other:

Required

First Name *

Last Name *

Street Address *

City *

State *

ZIP Code *

Please enter a 5-digit ZIP code

Phone Number (cell phone preferred) *

Can you receive Text Messages at this phone number? *

Yes

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