Current Page 1 Page 2 Page 3 Preview Personal health information on this form is collected by Health PEI for the purposes of your care and for other purposes permitted by the Health Information Act, including the planning and management of health services. Your information will be collected, used and disclosed only as permitted by law. For more information, visit www.healthpei.ca/yourprivacy or contact 1-844-344-8255. Identification First Name Middle Initial Last Name Address 1 Address 2 City, Town, or Community Province Postal Code For example C1B 0X1 or 12345 Country Telephone Number For example 902-555-5555 Email Address Pronouns - Select -She/HerHe/HimThey/ThemOther Specify pronouns Occupation Who is your family physician? Alternate Contact Alternate Contact Name Alternate Contact's Phone Number Alternate Contact Relationship - Select -SpousePartnerParentChildCaregiverOther Other alternative contact, please explain: