To be used by health care providers only. For all other referrals, contact Niagara Parents.
The public health nurse who is assigned may contact you for further information about the referral before contacting the client
* = Required
* First Name
* Last Name
* Date of Birth
Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln
* Postal Code
Client consents to receiving text or email when an alternate method of communication is required to contact them
* Is the patient pregnant?
Family involved with Family and Children's Services Niagara
Child is in foster / kinship care
Family requires support with the following (check all that apply):
Date of Birth
+ Add another child
Note: Depending on the family's needs, they may be offered appointments at a clinic, educational classes, online resources and / or a home visit. Additional referrals may also be facilitated as required.
Client has verbally consented to the disclosure of their personal health information for the purpose of a referral to Niagara Region Public Health
I agree to receive fax and / or email communication about this referral from Niagara Region Public Health
Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.
Freedom of Information
Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email firstname.lastname@example.org or call 905-980-6000 ext. 3779.
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