Out-of-Province Travel Support Application Form

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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 *

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.

Upload a copy of Physicians Note *

Files must be less than 2 MB.
Allowed file types: jpg jpeg txt pdf doc docx xls xlsx.