Men's Health Clinic Registration

Contact Information

* Name:

* Phone: xxx-xxx-xxxx  Ext.

* Email:

Are you experiencing any symptoms?

Preferred Contact Method: Select... Phone Text E-Mail

Preferred Meeting Information

Note: Locations and times are up for negotiation with the nurse.

Note: Locations and times are up for negotiation with the nurse.

 Date:

Time: 12 1 2 3 4 5 6 7 8 9 10 11 : 00 15 30 45 AM PM

Address

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.