Current Page 1 Page 2 Page 3 Page 4 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 Enter the child's 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 A confirmation email for this form will be sent to this address. Date of Birth Family Physician What language is most commonly spoken at home? - Select -EnglishFrenchOther Other language commonly spoken at home Parent Identification Fill in the address if different from above. To add another parent/guardian, click the Add button below. Parent/Guardian First Name Last Name Address City, Town, or Community Province Postal Code For example C1B 0X1 or 12345 Country Telephone Number For example 902-555-5555 Item weight Add more parent/guardian more parent/guardian Emergency Contact First Name Last Name Telephone Number For example: 902-555-5555