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COVID-19

Updating Chosen Name Form

Please note required fields are marked with an * Asterisk.

* I would like to have my Chosen Name updated on my COVID-19 Vaccine Certificate and understand I may be contacted by SMDHU to further verify my identity.
(YYYY-MM-DD e.g. 1980-01-01)
If you don’t have an Ontario Health Card number/COVID ID please enter all zero’s (e.g.0000000000)
* Gender






* Upload Valid ID/Documentation of former name
NOTE: We cannot accept Microsoft Word files. Only image (jpg, jpeg, and png) or Adobe PDF.
* Upload Valid ID/Documentation of Chosen Name
NOTE: We cannot accept Microsoft Word files. Only image (jpg, jpeg, and png) or Adobe PDF.

“The Health Unit collects personal information in the course of doing business. Personal information about you is collected directly from you or from the person acting on your behalf. Personal health information collected may include, for example, your name, date of birth, address, contact information, health card number, health history, and information you provide during visits or calls to the health unit.”

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