Français
Search and menus
Search and menus
Prince Edward Island
Online Services
Out-of-Province Travel Support Application Form
1
2
3
4
Identification
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
Personal Health Number (PHN)
*
Please enter the 8-digits from your PEI health card.
Medical Reason
*
Diagnosis that requires out-of-province service.
Location of Service
*
- Select -
Nova Scotia
New Brunswick
Is an essential escort requested?
*
An eligible essential escort is either a) one parent/guardian or designate for a child less than 18 years of age; or b) a person who is required to accompany a patient for medically necessary reasons for safe patient transport. A physician note is required.
- Select -
Yes
No
Upload a copy of Physicians Note
*
Files must be less than
8 MB
.
Allowed file types:
jpg jpeg txt pdf doc docx xls xlsx
.
Upload
Next Page >