2024 Granite City Back To School Clinic

Back to School Physical & Vaccine Clinic

Granite City High School Gym: 3101 Madison Ave., Granite City, IL 62040 Clinic Dates: July 25th and August 8th, 2024
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Gender*
Patient's Grade in the Fall of 2024*
Contact Number*
Please enter a valid phone number
Email Address
example@example.com
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Legal Guardian Name*

First NameLast Name
Has the patient ever received services from Madison County Health Department?*

YesNoUnsure
Does the patient have insurance? If yes, please fill in insurance information below.*

YesNoUnsure
Insurance Information
Insurance Company Name
Subscriber ID or Recipient ID
Group Number (if applicable)
Guarantor (primary person insured)
Please select appointment date (July 25th or August 8th) and time.*
Should be Empty:

Back to School Physical & Vaccine Clinic