Current Page 1 Page 2 Preview Personal health information on this form is collected for the purposes of the provision of health care. Your information will be collected, used and disclosed only as permitted by the Health Information Act, RSPEI 1988, c H-1.41, and other applicable legislation. For more information on privacy and your personal health information, visit www.healthpei.ca/yourprivacy or contact 1-888-561-2233. 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 Preferred Name Date of Birth Family Physician Do you have any mobility issues or physical limitations that we should be aware of for your appointment? - Select -YesNo