Intent to Donate and Language Information

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Consent to organ and/or tissue donation and language profile responses are voluntary and are not required for Health Card eligibility. Personal information on this form is collected under the authority of Section 31(c) of the Freedom of Information and Protection of Privacy Act.

Identification

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

Exemple : 902-555-5555

Email Address

Personal Health Number (PHN)

Enter the 8-digits from the PEI health card

Date of Birth

Are you 16 years of age or older?

First Name of Accompanying Parent/Legal Guardian

Last Name of Accompanying Parent/Legal Guardian

Accompanying Parent/Legal Guardian's Personal Health Number (PHN)

Enter the 8-digits from the PEI health card