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Macomb Community Action
Health and Community Services
21885 Dunham Road, Suite 10, Clinton Township, MI 48036
(586) 469-6999

Forms

Based on your age, please fill out the appropriate form below and bring it with you on the day of your appointment. Blank forms are available onsite if you are unable to print it at home.

Standard COVID-19 Vaccine Administration Record (Age 12 or Older)

Child COVID-19 Vaccination Form (Age 5 to 11 years old)

FDA Approved and Emergency Use Authorizations (EUA)

V-safe Information - V-safe is a smartphone-based tool that uses text messaging and web surveys to provide personalized health check-ins after you receive a COVID-19 vaccination.