PEI Health Card Application for New Residents

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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

Date of Birth *

For example: yyyy-mm-dd

Place of Birth *

Country and Province (if applicable)

Sex *

Citizenship Status *

Previous Residence

Previous Address *

Provide the full mailing address if your previous residence is within Canada, otherwise only your previous country of residence is required.

Residential Status *

Please indicate release date *

For example: yyyy-mm-dd

Date of arrival on Prince Edward Island *

For example: yyyy-mm-dd

Reason for coming to Prince Edward Island *

Other, please specify *

Are you enrolled as a full-time or part-time student/intern? *

Estimated graduation date *

For example: yyyy-mm-dd

Length of stay on Prince Edward Island *

How long will you be living on PEI? *

Organ and Tissue Donor Decision

The information below will be stored in a secure computerized PEI Donor Registry. In the future, your organ and/or tissue donor decision will be displayed on your new Health Card. For more information about organ and tissue donation, please call: 902-368-5920

I wish to donate organs needed for transplant. *

This includes lungs, heart, liver, kidneys, pancreas, small bowel.

I wish to donate tissues needed for transplant. *

This includes skin, eyes, bone and related structures, heart valves/pericardium.

Language Profile

In order to plan for service delivery, please answer the following questions related to your language profile. Your preferred language of service will be displayed on your new Health Card.

What is your mother tongue? *

The language you first learned in childhood and still understand.

If your mother tongue is neither English nor French, in which of Canada's official languages are you most comfortable?

What is your preferred language for service delivery? *