E-munization



CLICK HERE FOR DETAILED INSTRUCTIONS
Child's First Name: *     
Child's Last Name: *     
Gender: *       
Date of Birth: *         
Ontario Health Card Number (no spaces): *     
Note: If you don't have a health card number, type "none" in the field above.

Child's Physician: *     
Note: If you don't have a family physician, type "none" in the field above.

School / Day Care: *     
Parent/Guardian Name (first + last): *     
Home Phone Number: *     
Work Phone Number:     
Parent/Guardian Email Address:     
Note: we may use this email address to contact you in the future, about your child's
immunization record. We will not share this address with anyone else.