Child's Immunization Record

Please complete the following form to submit your child's immunization information. If your child attends a licensed child care centre, provide a copy of the immunization information to the child care operator.

Required fields are marked with an asterisk ( * )



Location


(If your child lives and/or attends a licensed child care or school OUTSIDE of Ottawa, please contact your local health unit.)

Child's Information



X X X X  •  X X X  •   (last 3 digits)


Parent/Guardian Information

ext.

ext.

If you provide an email address we will send you an email response, within 3 working days, confirming that your child’s record is now up to date or is still missing information.

Child's Physician Information

Vaccinations


Privacy Statement:

 

Child Care and Early Years Act:
Personal health information is collected on this form to create an immunization record and facilitate communications with the parent/guardian and physician regarding the immunization requirements.

 

Immunization of School Pupils Act:
Personal health information about the pupil is collected on this form to create an immunization record and will be used to facilitate communications with the parent/guardian and physician regarding the immunization requirements.

 

Address
Ottawa Public Health, 
100 Constellation Dr., 
Ottawa ON K2G 6J8 
Mail-Code: 26-44

Fax: 613-580-9660

Phone 613-580-6744 Monday to Friday, 9 am to 4 pm 

 

Questions regarding this collection may be addressed to:
Supervisor, Vaccine Preventable Diseases Program,
E-mail: Immunization@ottawa.ca