Audiology Referral | eServices Prince Edward Island

Current Page 1
Page 2
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

Are you looking for an adult or child referral?

In the fields below, enter the information for the child needing an audiology referral.

In the fields below, enter the information for the individual who needs an audiology referral.

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

A confirmation email for this form will be sent to this address.

Date of Birth

Personal Health Number (PHN)

Please enter the 8-digits from your PEI health card.

Personal Health Number (PHN)

Please enter the 8-digits from the child's PEI health card.

Who is the child's family physician?

Family Physician

Language spoken at home

Other, please specify

Parent/Guardian Information

First Name

Last Name

Is the parent/guardian's address different from above?

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

Alternate Contact Information

First Name

Last Name

Telephone Number

For example 902-555-5555

Email Address

Referral Source

Who is completing this form?

Other referral source, please specify

First Name

Last Name

Telephone Number

For example 902-555-5555

Email Address