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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

Do you have an IL Medicaid card?

NoticeSome Medicaid cards require a $3.90 copay.
If Yes Enter Medicaid #
May you be contacted at this number?
If no, how may we contact you?
Have you had a partner diagnosed with gonorrhea, chlamydia, or syphilis recently?
If you are a female is there any chance you could be pregnant?Pregnancy testing $10.00

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.

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

  • Breast & Cervical Cancer Program
  • Dental Clinic
  • Document Center
  • Emergency Prepardness
  • Environmental Health
  • Family Planning
  • Food Safety - News & Updates
  • Healthy Families Illinois
  • Home Health
  • Hospice
  • Medical Reserve Corps.
  • Prairie Counseling Center
  • Services
  • Vaccines
  • W.I.C.
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