This form is only for those who are part of the certified class-action lawsuit against Guelph Dental Associates. If you are part of the certified class-action lawsuit against Guelph Dental Associates and are looking for your hepatitis B/hepatitis C/HIV results in relation to this case, you must contact the physician or clinic from which the bloodwork was ordered. WDG Public Health will only have a record of your results if the tests were performed by us in one of our offices. If you were tested by WDG Public Health in relation to the Guelph Dental Associates case, please fill out the form below: First Name of Client * Last Name * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Email Phone number * Current Address * Address at the time of bloodwork request, if different City * Postal Code * I am the custodial parent/guardian submitting on behalf of my child * Yes No Parent/Guardian Name Personal information is collected under the authority of s. 53(1) of the Personal Health Information Protection Act. This information will be used for processing your access request, in compliance with legal and regulatory requirements. Any questions about the collection of personal information should be addressed to the Chief Privacy Officer, 160 Chancellor’s Way, Guelph ON, N1G 0E1, 1-800-265-7293 ex. 2975,privacy@wdgpublichealth.ca CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
