1 Current Page 1 2 Page 2 3 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 I am applying as a: - Select -Returning International StudentReturning Work Permit Holder 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) Provide the 8-digits (00123456) on the current PEI health card. Previous Residence Date of arrival on Prince Edward Island Reason for coming to Prince Edward Island - Select -Student/InternshipEmployment Are you enrolled as a full-time or part-time student/intern? - None -Full-timePart-time Estimated graduation date 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. 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?