Current Page 1 Page 2 Preview Personal health information on this form is collected by Health PEI for the purposes of your care and for other purposes permitted by the Health Information Act, including the planning and management of health services. Your information will be collected, used and disclosed only as permitted by law. For more information, visit www.healthpei.ca/yourprivacy or contact 1-844-344-8255. Identification Are you looking for an adult or child speech and language pathology referral? - Select -Adult ReferralPreschool Child Referral In the fields below, enter the information for the child (infant to preschool age) needing a speech language pathology referral. In the fields below, enter the information for the individual who needs a speech language pathology referral. 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 A confirmation email for this form will be sent to this address. Date of Birth Child's Date of Birth Personal Health Number (PHN) Please enter the 8-digits from the child's PEI health card. Personal Health Number (PHN) Please enter the 8-digits from your PEI health card. Who is the child's family physician? Who is your family physician? Language spoken at home - Select -EnglishFrenchOther Other, please specify Parent/Guardian Information Fill in the address if different from above. To add another parent/guardian, click the Add button below. Parent/Guardian First Name Last Name Address City, Town, or Community Province Postal Code For example C1B 0X1 or 12345 Country Telephone Number For example 902-555-5555 Item weight Add more parent/guardian more parent/guardian Alternate Contact Information First Name Last Name Telephone Number For example 902-555-5555 Email Address Referral Source Who is completing this form? - Select -I am completing this form for myselfEar, Nose, Throat Specialist (ENT)Family MemberNeurologist Nurse PractitionerPhysicianRespirologistSpeech Language Pathologist (S-LP)Other Who is completing this form? - Select -AudiologistEducatorEar, Nose, Throat Specialist (ENT)Family PhysicianNeurologist Occupational TherapistParent or GuardianPediatricianPediatric PsychologistPhysiotherapistPublic Health NursingSpeech Language Pathologist (SLP)Other Other referral source, please specify First Name Last Name Telephone Number For example 902-555-5555 Email Address