Men's Health Services Registration Form

Contact Information

* Name

* Email

* Phone
xxx-xxx-xxxx

Ext.

How should we contact you? Call
Text
Email

Do you speak English? Yes
No

What is the reason you want to see Nurse Scott?

What day works best for you? Any weekday
Monday
Tuesday
Wednesday
Thursday
Friday

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

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.