Program for Elementary Eye Care Registration

Current Page 1
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, you may contact the Vision Care program office at 902-213-2970.

Identification

Enter your contact information as the child's parent/guardian 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

Personal Health Number (PHN)

Enter the 8-digits from the PEI health card

Child's Information

First Name

Middle Initial

Last Name

Personal Health Number (PHN)

Enter the 8-digits from the PEI health card

Date of Birth

Does your child attend school or are they home schooled?

Name of School

Grade

Do you have private vision insurance for your child?

Acceptance

I certify that the information provided on this application for the PEI Program for Elementary Eye Care is accurate and true. I understand that it is an offence to give false information in this application. I acknowledge and understand that if it is determined that I have given false information in this application, I may be subject to legal sanction and I may be required to pay back the cost of any vision care received through this program.

CAPTCHA