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Disease of public health significance (DOPHS) notification form

After hours, weekends, and holidays, please call 613-507-3100 and have the on-call manager or director paged.
(Regular office hours are Monday to Friday 8:30 a.m. to 4:30 p.m.)

Diagnosis

Date of Diagnosis

Symptoms

Onset Date

Diagnosing health care provider

Phone number

Fax number

Email address

Reporting source

First name

Last name

Agency

Phone number (999-999-9999)

Email address

Patient information

First name

Last name

Phone number

Address

City

Province

Postal code

Date of birth

Sex at birth

Male

Female

Gender

Ontario Health Card number

Name of parent or guardian (if applicable)

Occupation

Place of employment

Family health care provider

Phone number (999-999-9999)

Fax number