Region of Waterloo Form

Required fields are marked with asterisks (*)

Welcome

Please complete this form to have a sexual health nurse contact you.  If you need help completing this form, you can call the Service First Call Centre at 519-575-4400. 

The sexual health team's hours are Monday to Friday 8:30 a.m. to 4:30 p.m.

Are you 18 years of age or younger?
 
What would you like to talk to a nurse about?
 
What is the best way to contact you?
 
When is the best time to reach you?
 


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