Reportable Disease Notification Form - DRAFT

The Personal Information on this form is collected under the authority of the Health Protection and Promotion Act and Personal Health Information Protection Act. This information will be used for delivery of public health programs and services and may be used for evaluation or statistical/research purposes. Any questions about the collection of this information should be directed to: Privacy Officer, Southwestern Public Health, 1230 Talbot Street, St. Thomas, ON N5P 1G9 or via Phone: 1-800-922-0096.
Patient Demographic Information
Full NameDate of BirthRelationshipComments
If you click yes, please fax all relevant documents to 519-633-0468
Please Note:
This HBHC service is provided for residents of St. Thomas, Elgin County, and Oxford County. If you do not reside in these areas, your information will be forwarded to the appropriate health unit.