Audiology Referral

  • 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

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.

For example C1B 0X1 or 12345
For example 902-555-5555
Please enter the 8-digits from your PEI health card.
Please enter the 8-digits from the child's PEI health card.
Parent/Guardian Information
For example C1B 0X1 or 12345
For example 902-555-5555
Alternate Contact Information
For example 902-555-5555
Referral Source
For example 902-555-5555