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PEI Provincial Patient Registry Application Form

Fields marked with a red star (*) are mandatory.

Last Name: *
First Name: *
Day of Birth: *
Month of Birth: *
Year of Birth: *
Sex: *
Male
Female
PEI Health Card Number (8 digits): *
Number and Street: *
City, Town or Community: *
Province: *
Postal code: *
Home Tel: *
Work Tel:
Email Address: *
Previous Family Physician: *
Preferred Region of new Physician (check one): *
Eastern Kings(Souris)
Southern Kings(Montague)
Queens(Charlottetown)
Central Queens(Hunter River,Rustico)
East Prince(Summerside)
West Prince (Tyne Valley, O'Leary, Alberton, Tignish)
Are you a new resident of Prince Edward Island ?: *
Yes
No
If yes, what was your previous province /country of residence:
Have you moved within PEI?:
Yes
No
Other family members living at the same address requiring a family physician


1.Name:
Date of Birth:
PEI Health Card Number (8 digits):
Sex:
Female
Male
2. Name:
Date of Birth:
PEI Health Card Number (8 digits):
Sex:
Female
Male
3.Name:
Date of Birth:
PEI Health Card Number (8 digits):
Sex:
Female
Male
4.Name:
Date of Birth:
PEI Health Card Number (8 digits):
Sex:
Female
Male
5.Name:
Date of Birth:
PEI Health Card Number (8 digits):
Sex:
Female
Male
Privacy Statement:


The personal information collected from you for the Patient Registry is collected for the purpose of assisting you to obtain a family doctor . The information will not be used for anything else and is collected in accordance with the Freedom of Information and Protection of Privacy Act. If you have questions about this collection of your personal information you may contact the Privacy and Information Access Coordinator at (902) 368-4942.

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Please send me a simple text-only version of the information I submitted.
Please send me an Acrobat version of the form, with the information I've entered above filled in, that I can print and save.
Please send me both the text-only version and the PDF.
Important Note: Email is not, by its very nature, a secure medium; if you choose to have your form emailed to you, the information you entered will be transmitted over the public Internet to your email box.

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When you click here, the information you've entered above will be sent to the public servant responsible for receiving and processing this form. If you've opted to receive an Acrobat version of the form by email, you will receive this file shortly.
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