2025 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 31st and August 7th, 2025
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Gender*
Patient's Grade in the Fall of 2025*
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 31st or August 7th) and time. JULY 31ST IS FULL*
Should be Empty:

Back to School Physical & Vaccine Clinic