STD FORM – Bond County Health Department

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Bond County Health Department

Bond County Health Department
1520 South Fourth Street
Greenville, Illinois 62246
Phone: (618) 664-1442 Fax: (618) 664-2261
STD INFORMATION SHEET
ALL INFORMATION GIVEN TO THE STD NURSE IS STRICTLY CONFIDENTIAL

Last Name

First Name

Do you have an IL Medicaid card?

Yes

NoticeNoSome Medicaid cards require a $3.90 copay.

Medicaid#:If Yes Enter Medicaid #

Today's Date

Date of Birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

May you be contacted at this number?YesNo

If no, how may we contact you?EmailContact Other

Phone

Email Address

Contact Name/Number:

Please list any allergies to medications:

Have you had a partner diagnosed with gonorrhea, chlamydia, or syphilis recently?YesNo

IF YES, PLEASE PRINT THE NAME OF YOUR PARTNER AND DIAGNOSIS:

If you are a female is there any chance you could be pregnant?YesNoPregnancy testing $10.00

Notice

I do hereby affirm that above information is true, correct, and current. By signing this form, I am giving my permission to be tested, counseled, and treated if necessary, by the STD nurse in accordance with the current CDC treatment guidelines. I understand that I may be contacted by Bond. County Health Department concerning my test results.

Signature

Patient's Signature

Date

Signature

Nurse's Signature Revised 2/09, 07 /12, 02/16, 02/18, 03/18, 09/19, 01/23

Date

TYPE OF SERVICE YOU ARE REQUESTING:GONORRHEA/CHLAMYDIA TESTING $10.00HIV TESTING (BLOOD DRAW) $10.00SYPHILIS TESTING (BLOOD DRAW) $10.00TREATMENT FOR GONORRHEA/CHLAMYDIA $15.00

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