Child name Child birthdate Parent name Best phone number to contact you Email address City School Other Information Type of screening desired

Check all that apply

Hearing and vision
Kindergarten oral health assessment
Immunization

Please bring your insurance card if screening for Immunization

Date desired:

All dates are on a Thursday at the COLDWATER office

June 12
June 26
July 10
July 24
July 31
August 7
August 14
Time preferred:
9:00am to 12 noon
1:00pm to 3:00pm

Sturgis office only
August 12
10:00am to 5:00pm

Hillsdale office only
August 8
9:00am to 3:00pm

Three Rivers office only
August 6
9:00am to 3:00pm