Order Clinical and Patient Resources

Resources to Order

Contact Information

* Name

Name of Practice

Type of Practice Family Practice Walk-in Clinic Dental Office Hospital OB/GYN Midwifery Other

* Phone xxx-xxx-xxxx

Ext.

Email

Delivery Information

* Address

* City / Town Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln

* Postal Code

Personal Information and Privacy

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.

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email our Access and Privacy Office or call 905-980-6000 ext. 3779.