1 Current Page 1 2 Preview Personal information on this form is collected under section 31(c) of the Freedom of Information and Protection of Privacy Act R.S.P.E.I. 1988, c.F-15-01 as it relates directly to and is necessary for the Electronic Medical Record Expression of Interest Application. If you have any questions about this collection of personal information, you may contact firstname.lastname@example.org. Information may be verified. Identification Community-based physicians and nurse practitioners are invited to put forward their expression of interest to learn more about implementing an Electronic Medical Record (EMR). This is not a commitment to begin the implementation process, only to learn more. This form may also be completed on behalf of health-care providers by a clinic lead or office manager. I am - Select -A Provider submitting my own Expression of InterestA Clinic Lead/Office Manager submitting on behalf of a group Please insert the name of the clinic and contact information. Business/Organization Name Contact First Name Contact Last Name Address 1 Address 2 City, Town, or Community Province Postal Code For example C1B 0X1 or 12345 Country Telephone 1 For example 902-555-5555 Telephone 2 For example 902-555-5555 Fax Number For example 902-555-5555 Email Address Someone from the EMR Program Team will be in touch to discuss your interest and learn about your practice. Best time to contact you Math question 2 + 5 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.