Back to School Physical & Vaccine Clinic
Granite City High School Gym: 3101 Madison Ave., Granite City, IL 62040 Clinic Dates: July 30th and August 6th, 2026
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Gender
*
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Male
Female
Prefer Not to Answer
Patient's Grade in the Fall of 2026
*
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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
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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 30th or August 6th) and time.
*
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