Current Page 1 Page 2 Preview The personal information in your COVID-19 Vaccine Record that you are providing to the Chief Public Health Office is collected under the authority of the Public Health Act, RSPEI 1988, c P-30.1 for the purpose of maintaining a provincial immunization registry. Identification Provide your full name and the phone number on which you prefer to be contacted in the fields below. The PEI Chief Public Health Office may need to contact you to clarify information provided in this form. Personal Health Number (PHN) Please enter the 8-digits from your PEI health card. If you do not have a PEI health card, you can find more information online, or call the Medicare Office at 1-800-321-5492 (toll-free). 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 The Department of Health and Wellness and Health PEI has partnered with CANImmunize to make it easier for you to keep track of your COVID-19 vaccination records. Do you consent to have CANImmunize send you a digital receipt of your vaccination record by secure email? - Select -YesNo Confirm Email Address Date of Birth Do you have a health card number in another province or territory where you received your COVID-19 vaccine? - Select -YesNo Out-of-Province Health Card Number