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.

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?

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