Search

Go to the COVID-19 Search to search all COVID-19

Go to the News search to search all news

Displaying 1 - 10 of 73.

Results

Substance Use Harm Reduction Client Registration Form

https://www.princeedwardisland.ca/sites/default/files/forms/substance_use_harm_reduction_client_registration_form.pdf
2022-05-18
PATIENT REGISTRATION FORM SUBSTANCE USE HARM REDUCTION DRUG PROGRAM Fax requests to (902) 368-4905 OR mail requests to PEI Pharmacare, P....

Out-of-Province Travel Support Application

https://www.princeedwardisland.ca/sites/default/files/forms/out-of-province_travel_support_application.pdf
2022-03-30
Complete this form to apply for out-of-province travel support for medical services with the Maritime Bus Program. Apply online at least 10 days prior to out-of-province travel.
Microsoft Word - FINAL_OPP Travel Application Form_07-30-2014.doc Maritime Bus Program Questions & Answers Who is eligible?  Applicant must have approval from Health PEI for out-of-province medical services.  Applicant must be a PEI...

Home Oxygen Program Application Form

https://www.princeedwardisland.ca/sites/default/files/forms/home_oxygen_program_application_form.pdf
2022-03-28
Complete this form if you have been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and have been prescribed oxygen. You may be eligible for coverage of expenses through the Home Oxygen Program.
Home Oxygen Program Application Form The PEI Home Oxygen Program provides approved patients with financial assistance of up to 50% of their approved home oxygen expenses to a maximum of $200 per month. Approved expenses are limited to...

Orthopaedic Intervention Clinic Referral Form

https://www.princeedwardisland.ca/sites/default/files/forms/orthopaedic_intervention_clinic_referral_form.pdf
2022-03-25
Primary Care Providers and Allied Health Professionals can refer patients and clients to the Orthopaedic Intervention Clinic by completing this form and faxing it to , 902-368-6921.
Orthopaedic Intervention Clinic Referral Form Cathy Nabuurs, Orthopaedic Nurse Practitioner (Non-operative management for Hips, Knees & Shoulders) Primary Care Network Queens East 199 Grafton Street, Charlottetown, PE C1A 1L2...

Rheumatoid Arthritis Special Authorization Request Form

https://www.princeedwardisland.ca/sites/default/files/forms/rheumatoid_arthritis_special_authorization_request_form.pdf
2022-03-24
Special authorization request form to be completed by your physician or diagnosing specialist.
SPECIAL AUTHORIZATION REQUEST RHEUMATOID ARTHRITIS Fax requests to (902) 368-4905 OR mail requests to PEI...

Medical Assistance in Dying (MAiD) Patient Request and Consent Form

https://www.princeedwardisland.ca/sites/default/files/forms/medical_assistance_in_dying_patient_request_and_consent_form.pdf
2022-02-08
This consent form is required to participate in the MAiD process. Individuals are encouraged to complete the consent form in advance of their assessment with the MAiD provider. Consent can be withdrawn or cancelled at any time. For more information, visit Medical Assistance in Dying .
Patient Label Medical Assistance in Dying (MAID) Patient Request and Consent Form Please review this form carefully. Feel free to ask any questions about this form, now or at any time during your interactions with your health care providers. o The...

Cardiac Rehab Referral Form

https://www.princeedwardisland.ca/sites/default/files/forms/cardiac_rehab_referral_form.pdf
2022-01-19
Your physician or nurse practitioner can refer you to the , Cardiac Rehab Program,  by submitting this referral form. An exercise stress test , must,  be sent in with your referral. If you meet the inclusion criteria for the program, you will be contacted for an assessment appointment. For more...
Appendix 1: REFERRAL FORM REFERRAL FORM: CARDIAC Rehabilitation Program Date of referral: ______________ Physician/NP Signature: _______________________ Print Name:__________________ Send referrals to: Lindsay Hansen, Provincial...

Pulmonary Rehab Referral Form

https://www.princeedwardisland.ca/sites/default/files/forms/pulmonary_rehab_referral_form.pdf
2022-01-19
Your physician or nurse practitioner can refer you to the , Pulmonary Rehab Program,  by submitting this referral form. If you meet the inclusion criteria for the program, you will be contacted for an assessment appointment. For more information, visit the Cardiac and Pulmonary Rehab Programs .  
Appendix 1: REFERRAL FORM REFERRAL FORM: Pulmonary Rehabilitation Program * Please see inclusion/ exclusion criteria on reverse to ensure referral is appropriate Date of referral: ______________ Have you discussed pulmonary...

Influenza Immunization Clinic Registration Form

https://www.princeedwardisland.ca/sites/default/files/forms/influenza_immunization_clinic_registration_form.pdf
2021-10-06
To receive a flu vaccination, you must complete a registration form. Complete the top section of this form and bring it with you to a vaccination clinic.
Influenza Immunization Clinic Registration Form Health PEI Influenza Immunization Clinic Registration Form Date: ___________________ Client Name: _________________________________________ DOB: ___________________ Age: _______________ Sex:...

Preschool Speech and Language Pathology Referral Form

https://www.princeedwardisland.ca/sites/default/files/forms/preschool_speech_and_language_pathology_referral_form.pdf
2021-10-04
Referral form for your child to be seen by Speech Language Pathology.
Preschool Speech and Language Pathology Referral Name: Date of Birth: (D/M/Y) Personal Health Number (Provincial Health Card): Home Telephone: Work Telephone: Cell Telephone: Name of Parent/Guardian/Contact: Address: Email: Would you...

Content Type

Category

Service Category

Departments and Agencies

Published Date

General Inquiries

Contact Government
or use the Feedback tab to share your comments and feedback