Current Page 1 Preview Personal information on this form is collected by Health PEI under the authority of Section 31(c) of the Freedom of Information and Protection of Privacy Act and the Health Information Act. We will use this information for the purposes of processing your request. For more information on the collection, use or disclosure of your information, visit www.healthpei.ca/yourprivacy or speak with your health care provider. Identification Are you requesting the report for your child/dependent? - Select -YesNo Enter parent/guardian 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 - Select -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Telephone Number For example 902-555-5555 Email Address Date of Birth Provide your PEI Health Card Number (PHN) or PEI Medical Record Number (MRN). (optional if you do not have a PEI health card or MRN) Please enter the 8-digits from your PEI health card or 9-digit Medical Record Number. Child/Dependent Information Enter each child/dependent's information in the fields below. Enter each child/dependent's information in the fields below. Child's First Name Child's Last Name Address Provide Child's PEI Health Card Number (PHN) or PEI Medical Record Number (MRN) Please enter the 8-digits from your PEI health card or 9-digit Medical Record Number. City, Town, or Community Postal Code For example C1B 0X1 or 12345 Telephone Number For example 902-555-5555 Item weight Add more child/dependent more child/dependent Documentation You may need to reduce the file size of your document to <2mb. Read Resizing Photos for Online Forms or search online for information about your specific device. Upload a copy of your Government issued photo identification One file only.5 MB limit.Allowed types: gif, jpg, png, jpeg, txt, rtf, pdf, doc, docx, ppt, pptx, xls, xlsx. Documentation You may need to reduce the file size of your document to <2mb. Read Resizing Photos for Online Forms or search online for information about your specific device. Upload a copy of the child's health card or Government issued photo identification One file only.5 MB limit.Allowed types: gif, jpg, png, jpeg, txt, rtf, pdf, doc, docx, ppt, pptx, xls, xlsx. Upload a copy of parent/guardian's Government issued photo identification One file only.2 MB limit.Allowed types: gif, jpg, png, jpeg, txt, rtf, pdf, doc, docx, ppt, pptx, xls, xlsx. Testing Information Location of Testing - Select -Borden-Carleton, 20 Dickie RoadCharlottetown AirportCharlottetown, 64 Park StreetConfederation BridgeMontague, 14 Rosedale RoadO'Leary, 14 MacKinnon DriveSummerside, Slemon ParkWood Islands Date of Testing Additional Information Email Confirmation I understand that there are risks associated with sending personal information to a private, unsecured email address, including a risk that my information could be accessed by someone else in transit. I accept the risk and request that Health PEI send my personal information to me at the email address I have provided below. Confirm your email address Math question 6 + 3 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.