Request for Non-Surgical Gender-Affirming Procedures

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Prefill with your MyPEI Account

Allow this form to use information already in your MyPEI account to fill in fields automatically. You can review and edit everything before submitting.

Personal information on this form is collected under section 31(c) of the Freedom of Information and Protection of Privacy Act R.S.P.E.I. 1988, c.F-15-01 as it relates directly to and is necessary for determining eligibility. If you have any questions about this collection of personal information, you may contact the Gender-Affirming Clinic Health PEI at 902-288-1850.

Identification

Provide the patient information 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

Preferred Name

Preferred Pronouns

Date of Birth

Personal Health Number (PHN)

Enter the 8-digits from the PEI health card

Who is filling out this form?

Contact Information

Enter the contact information as the person filling out the form in the fields below.

First Name

Last Name

Telephone Number

For example 902-555-5555.

Email Address