Immunization Reporting
Use this form to submit your immunization dates for your child(ren). Once we receive your information, we will update our immunization records accordingly. All fields marked with a '*' are mandatory.

If you have any questions or concerns about submitting immunization records online, or do not have an Ontario Health Card number please contact us at 519-355-1071 ext. 5900.

* Indicates a mandatory field 
Last Name: * E-mail:
First Name: * Parent/Guardian's Name: *
Gender: * Male Female 911/Street Number: *
Date of Birth: * Street Name: *
Ontario Health Card #: * City: *
Physician: Postal Code: *
School: Phone # - Primary: *
Child Care Centre: Phone # - Other:
Site/Location:

























 


Add Immunization


This information is collected in order to maintain an immunization record for the named individual. Information is collected under the authority of the Immunization of School Pupils Act, R.S.O. and the Child Care and Early Years Act, 2014. Notifying CK Public Health of vaccinations assists the health unit in maintaining an accurate immunization record for your child(ren). Please note that all immunization information is confidential. However, for the purpose of ensuring continuity of care, this information will be released to your health care provider upon their request unless you specifically request the health unit to withhold your immunization status.
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