1 Current Page 1 2 Page 2 3 Page 3 4 Preview Personal information on this form is collected under Section 8 (Registration of Entitled Persons) of Prince Edward Island’s Health Services Payment Act (Regulations) and will be used to ensure a resident’s entitlement in respect to basic health services. If you require additional information, please contact Medicare Services, 126 Douses Road, Montague, PE C0A 1R0, 1-800-321-5492. 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 For example 902-555-5555 Email Address Date of Birth Place of Birth Country and Province (if applicable) Sex - Select -MaleFemale Citizenship Status - Select -Canadian CitizenCanadian citizen returning from another countryPermanent ResidentInternational StudentWorking Visa Note: You are required to submit a verification letter for your proof of current enrollment from your school, along with a copy of your Study Permit, before your application will be processed. Previous Residence Previous Address Provide the full mailing address if your previous residence is within Canada, otherwise, only your previous country of residence is required. Residential Status - Select -New ResidentReturning Resident to PEIPermit RenewalArmed ForcesPenitentiary Note: You are required to submit a verification letter for your proof of current enrollment from your school, along with a copy of your Study Permit, before your application will be processed. Please indicate release date Date of arrival on Prince Edward Island Reason for coming to Prince Edward Island - Select -Student/InternshipEmploymentOther Are you enrolled as a full-time or part-time student/intern? - Select -Full-timePart-time Estimated graduation date For example: yyyy-mm-dd Other, please specify Length of stay on Prince Edward Island - Select -PermanentTemporary How long will you be living on PEI? Organ and Tissue Donor Decision The information below will be stored in a secure computerized PEI Donor Registry. In the future, your organ and/or tissue donor decision will be displayed on your new Health Card. For more information about organ and tissue donation, please call: 902-368-5920. I wish to donate organs needed for transplant. This includes lungs, heart, liver, kidneys, pancreas, small bowel. - Select -YesNo I wish to donate tissues needed for transplant This includes skin, eyes, bone and related structures, heart valves/pericardium. - Select -YesNo Language Profile In order to plan for service delivery, please answer the following questions related to your language profile. Your preferred language of service will be displayed on your new Health Card. If you would like a Unilingual French card please feel free to contact the Medicare Office at 1-800-321-5492. What is your mother tongue? The language you first learned in childhood and still understand. If your mother tongue is neither English nor French, in which of Canada's official languages are you most comfortable? - None -EnglishFrenchNeither What is your preferred language for service delivery?