Current Page 1 Page 2 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 Use your current mailing address in the fields below. Submit a new application for each household member. I am applying as a: - Select -Returning International StudentReturning Work Permit HolderNew Permanent Resident First Name Middle Initial Last Name Address 1 Address 2 City, Town, or Community Province Postal Code For example C1B 0X1 Country Telephone Number For example 902-555-5555 Email Address Personal Health Number (PHN) Enter the 8-digits from the PEI health card Date of Birth Sex - Select -MaleFemaleOther Are you 16 years of age or older? - Select -YesNo 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 Previous Residence Date of arrival on Prince Edward Island Reason for coming to Prince Edward Island - Select -Student/InternshipEmploymentOther Other reason, please specify. Are you enrolled as a full-time or part-time student/intern? - None -Full-timePart-time Estimated graduation date Intention to be an Organ and Tissue Donor The information below will be stored in a secure computerized PEI Intent to Donate Registry. In the future, your intention to donate organs and/or tissues will be displayed on your new PEI Health Card. I intend to donate organs needed for transplant This includes lungs, heart, liver, kidneys, pancreas, small bowel. - Select -YesNo I intend to donate tissues needed for transplant This includes skin, eyes, bone and related structures, heart valves/pericardium. - Select -YesNo By checking this box, I am declaring that I am 16 years of age or over, or that I am the parent or legal guardian of a person age 15 or younger. 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? - Select -EnglishFrenchNeither What is your preferred language for service delivery?