Actuel Page 1 Page 2 Aperçu Available to community-based health-care providers and those working in mental health and addictions. If you need assistance completing this form please email VirtualCare@ihis.org. 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, Cap. F-15.01, as it relates directly to and is necessary for the provision of COVID-19 Zoom Licenses. If you have any questions about this collection of personal information, you may contact Jennifer Lonaphy at 902-367-4637. Identification Provide Health Care Provider name and contact details. Prénom Initiale Nom Adresse 1 Adresse 2 Ville, municipalité, communauté Province Code postal Exemple : C1B 0X1 ou 12345 Pays Numéro de téléphone Exemple : 902-555-5555 Adresse courriel Note: If you are a Health PEI Employee, use your ihis.org email address. Manager's Email Address (If applicable)