Application for Biosimilar Switching Exemptions

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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.

Enter patient information in the fields below.
For example C1B 0X1 or 12345
For example 902-555-5555
Please enter the 8-digits from the patient's PEI health card.
Health Care Provider Information
For example: 902-555-5555
For example: 902-555-5555
Contact Information
For example: 902-555-5555