BCHD is strategically administering COVID-19 vaccinations to those who meet the CDC's high priority groups and according to guidance provided by the Michigan Department of Health and Human Services. Please fully complete the following survey to appropriately pre-register for the COVID-19 vaccination wait list or to indicate if you are in need of a second dose of the vaccine. We will be back in touch with you according to the contact method you prefer when we have appointment availability. It may be several weeks before we contact you with notification of appointment availability. Please be patient and do not submit this form more than once. 

(Please complete one survey per person)

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. Date of Birth (MM/DD/YYYY)

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* 4. Email Address

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* 5. Phone Number

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* 6. Which contact method do you prefer? (e-mail will be the quickest way to receive information from BCHD)

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* 7. Zip Code of Residence

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* 8. Have you received any type of COVID-19 vaccine?

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