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

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 foi@niagararegion.ca or call 905-980-6000 ext. 3779.