Back to School Physical & Vaccine Clinic
Granite City High School Gym: 3101 Madison Ave., Granite City, IL 62040 Clinic Dates: July 31st and August 7th, 2025
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Gender
*
Please Select
Male
Female
Prefer Not to Answer
Patient's Grade in the Fall of 2025
*
Please Select
Kindergarten
1st Grade
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Contact Number
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Please enter a valid phone number
Format: (000) 000-0000.
Email Address
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Patient's Address
*
Street Address
Street Address Line 2
City
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State
Zip Code
Parent/Legal Guardian Name
*
First Name
Last Name
Has the patient ever received services from Madison County Health Department?
*
Yes
No
Unsure
Does the patient have insurance? If yes, please fill in insurance information below.
*
Yes
No
Unsure
Insurance Information
Insurance Company Name
Subscriber ID or Recipient ID
Group Number (if applicable)
Guarantor (primary person insured)
Please select appointment date (July 31st or August 7th) and time. JULY 31ST IS FULL
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