COVID-19 Vaccine Registration Brighton
IEP Urgent Care has been approved as a COVID-19 vaccination site.  If you are interested in receiving the vaccine, please fill out this form and we will notify you as soon as it is available.  More information on Michigan Covid-19 Vaccine Prioritization Guidance can be found by copying and pasting the below link in your browser:
MI_COVID-19_Vaccination_Prioritization_Guidance_2152021_716344_7.pdf

Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Cell Phone Number *
VACCINE PRIORITIZATION SCHEDULE
Which prioritization group describes you? *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Independent Emergency Physicians. Report Abuse
Google Forms