Current Page 1 Preview Personal information and personal health information will be collected for the purpose of providing clients with the appropriate services. Personal information is collected under section 31(c) of Prince Edward Island's Freedom of Information and Protection of Privacy (FOIPP) Act. If you have any questions, contact the Cancer Patient Navigator at 902-894-2552. Identification Who are you seeking support for? - Select -MyselfMy Partner/SpouseMy Friend/Family MemberA Patient/Client Provide the contact information for the person you are referring. First Name Last Name Date of Birth Please provide a brief description of the patient/client’s situation Please provide a brief description of your situation Please provide a brief description of your partner or spouse’s situation Please provide a brief description of your friend or family member’s situation How do you wish to be contacted? - Select -EmailTelephone How do they wish to be contacted? - Select -EmailTelephone Contact Email Address Contact Telephone Number For example: 902-555-5555 I agree to inform my spouse/partner that I am referring them to the Cancer Patient Navigator and I acknowledge that I will be identified as the person who referred them. I agree to inform my friend/family member that I am referring them to the Cancer Patient Navigator and I acknowledge that I will be identified as the person who referred them. Your Information Who is filling out this form? - Select -PhysicianNurseNurse PractitionerAllied Health ProfessionalService ProviderCommunity Support Worker First Name Last Name Do you wish to be contacted by the navigator? Yes, I wish to be contacted. No, only contact me if more information is required. How do you wish to be contacted? - Select -EmailTelephone Preferred Contact - Select -EmailTelephone Telephone Number For example 902-555-5555 Email Address Fax Number For example 902-555-5555 I would like to connect with the navigator before this patient/client is contacted. I am the Primary Care Provider and I would like to receive a summary letter from the navigator. (Please ensure an email address or fax number has been provided.) CAPTCHA Math question 3 + 3 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.