Please fill out the form below to complete your request. Upon submitting the form you will be taken to PayPal where you can pay the $5 fee by Credit Card or PayPal. You must have JavaScript enabled to use this form. Request for: - Select -Access to General RecordsAccess to own Personal InformationCorrection to Own Personal Information Salutation - Select -Mr.Mrs.Ms.Miss First name: Last name: Address: City / Town / Province Postal Code Phone (day): Email: Request: Please provide a detailed description of requested records, personal information, or personal information to be corrected. If you are requesting a correction of personal information, please describe the desired correction, and attach any supporting documentation. If you are requesting access to your own personal information, please include a copy of a signed form of identification. Attachments: Unlimited number of files can be uploaded to this field.100 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Preferred method of Access to Records: - Select -PaperElectronicExamine Originals at Hospital This personal information is being collected under the authority of the Public Hospitals Act R.S.O. 1990, CHAPTER P.40 for the purpose of contacting the sender in response to an inquiry. If you have questions about the collection of this information, please contact Privacy and Freedom of Information, St. Joseph's Health Care London, 268 Grosvenor Street, London, ON,519-646-6100 ext. 65591.
