Clone of UTHS Mobile Clinic

Bettendorf High School Physical & Immunization Clinic

Thursday, July 23rd, 2026, 9:00am-3:00pm and Thursday August 6th, 2026 9:00am-3pm
***Please note that the clinic may be subject to cancellation if we do not have enough participants registered in advance.***
Appointment
Parent/Guardian Name

First NameLast Name
E-mail
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Child's Date of Birth

MonthDayYear
Date
Contact Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
Are you interested in enrolling in MyChart patient portal?
Should be Empty:

Bettendorf High School Physical & Immunization Clinic