This form is for children under the age of 18 who live in Wellington County, Dufferin County and Guelph.
*Mandatory fields

When you submit information through this secure online reporting system, you are consenting to the collection and use of your child’s personal health information to update, and maintain your child’s immunization records in our database.

Child's Personal Information

Contact Information:

*Immunization History

Specify the DATE and TYPE of vaccine(s) given as written on your child’s immunization record (e.g., yellow card).

Date of Vaccination Type of Vaccine

For vaccines not listed above, please provide the date (YYYY/MM/DD) and the name of the vaccine.

Notice of Collection

The information on this form is collected under the authority of the Personal Health Information Protection Act, the Personal Health Information and Protection Act, and Immunization of School Pupils Act, and the Day Nurseries Act, R.S.O. 1990. By completing this form, you are consenting to the collection and use of your personal health information by Wellington-Dufferin-Guelph Public Health for the delivery of public health programs and services, maintenance of the provincial immunization database, and registries and related research, in compliance with legal and regulatory requirements. Any questions about the collection of this information should be addressed to the Chief Privacy Officer at 1-800-265-7293 ext. 2975.

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