Lyme Disease Reporting Form

Lyme disease is reportable to Public Health as per O. Reg 135/18 under Health Protection and Promotion Act.

* = Required

Health Care Provider Information

Patient Information

* Gender    

* Date of birth

Signs and Symptoms

Patients with a single erythema migrans skin lesion can be seronegative at the time of initial presentation. A lesion greater than five centimetres in diameter consistent in appearance to erythema migrans in individuals exposed to blacklegged ticks in risk areas such as Niagara is considered confirmation of early localized Lyme disease and should be treated without laboratory confirmation.

Rash other than erythema migrans  

Central nervous system symptoms  

Peripheral nervous system symptoms  

Muscle / joint pain  

Swollen lymph nodes  





Heart block  

General weakness  


Serology ordered?  

Repeat serology ordered?  


Are you diagnosing Lyme disease?  

If yes, has the patient been notified of the diagnosis?  

Did you prescribe treatment?  

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.

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 or call 905-980-6000 ext. 3779.

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