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Haldimand-Norfolk - Out of Province Reporting

Please note this reporting form is only for residents of Haldimand-Norfolk.

 
If you have received your COVID-19 vaccination outside of Ontario, please complete the form below.

Proof of vaccination is required. Enhanced vaccination records are required for all Canadian provinces. 

Enhances vaccination certificates, including a QR code is a preferred form of verification for all international records. Enhanced certificates will be processed first.

If you are unable to obtain an enhanced vaccination certificate (QR code), additional information may be requested and the records may take up to 30 days to be processed.

Please be sure to upload your proof of vaccination at the bottom of the page.

*Once your record has been successfully added to the database you will receive an email confirmation.

 

The personal health information on this form is being collected for the purpose of providing care to you and creating an immunization record for you, and because it is necessary for the administration of Ontario''s COVID-19 vaccination program. This information will be used and disclosed for these purposes, as well as other purposes authorized and required by law. For example, it will be disclosed to the Chief Medical Officer of Health and Ontario public health units where the disclosure is necessary for a purpose of the Health Protection and Promotion Act. And it may be disclosed, as part of your provincial electronic health record, to health care providers who are providing care to you. The information will be stored in a health record system under the custody and control of the Ministry of Health. Where a Clinic Site is administered by a hospital, the hospital will collect, use and disclose your information as an agent of the Ministry of Health. You must consent to this to complete this form. (Required)
Gender (Required)
Date of Birth Please select your date of birth (Format: yyyy-mm-dd. The minimum date is '1924-03-28'. The maximum date is '2034-03-28'. Required)
Ontario Health CardPlease upload a copy of your Health Card (Required)
Address (Required)
Which dose are you reporting for? (Required)
Please upload your proof of vaccination. (Required)
Date vaccine was received (Format: yyyy-mm-dd. The minimum date is '1924-03-28'. The maximum date is '2034-03-28'. Required)
Please upload your proof of vaccination. (Required)
Date vaccine was received. (Format: yyyy-mm-dd. The minimum date is '1924-03-28'. The maximum date is '2034-03-28'. Required)
Please upload your proof of vaccine. (Required)
Date vaccine was received. (Format: yyyy-mm-dd. The minimum date is '1924-03-28'. The maximum date is '2034-03-28'. Required)
Please upload your proof of vaccination. (Required)