COVID-19 - Get vaccinated and find public health advice for residents and businesses.
Your form has been received. An inspector will follow-up with the client within 24 hours.
* = Required
* Physician
Address
City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln
Postal Code
* Phone xxx-xxx-xxxx
Fax xxx-xxx-xxxx
* First Name
* Last Name
Date of Birth Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 12345678910111213141516171819202122232425262728293031 Year 2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914191319121911191019091908190719061905190419031902190119001899189818971896189518941893189218911890188918881887188618851884188318821881188018791878187718761875187418731872
Health Card Number Verified Yes No
Guardian information (name and contact information, if different from above)
First Name
Last Name
Phone xxx-xxx-xxxx
Relation to Person Bit
Date of Exposure
Area on Body
Type of Animal Select Animal... Dog Cat Bat Other
Type of Exposure Select Type... Bite Scratch Handling Saliva Other
Rabies Vaccine Recommended Yes No
Animal's Habitat Select Habitat... Domestic Stray Wild
Description of Animal
Circumstances
PatientAcceptsDeclines
If you don't know the animal owner's information, please type "unknown" in the fields below.
* Address
City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln Other
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 foi@niagararegion.ca or call 905-980-6000 ext. 3779.