Current Page 1 Page 2 Preview Personal information on this form is collected under Prince Edward Island's Health Information Act as it relates directly to and is necessary for providing services under the PEI Pharmacare Drug Programs. If you have any questions about this collection of personal information, you may contact the program office at 902-368-4947. Identification Enter patient information in the fields below. 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 Date of Birth Personal Health Number (PHN) Please enter the 8-digits from the patient's PEI health card. Who is filling out this form? - Select -PatientHealth Care ProviderOther Health Care Provider Information Profession License Number First Name Last Name Telephone Number For example: 902-555-5555 Fax Number For example: 902-555-5555 Contact Information Relation to Patient First Name Last Name Telephone Number For example: 902-555-5555