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Clinique de vaccination antigrippale Formulaire d'inscription

https://www.princeedwardisland.ca/sites/default/files/forms/clinique_de_vaccination_antigrippale_formulaire_dinscription.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:...

Demande de consultation en orthophonie

https://www.princeedwardisland.ca/sites/default/files/forms/demande_de_consultation_en_orthophonie_formulaire.pdf
2021-10-04
Formulaire de référence pour que votre enfant soit vu par un orthophoniste.
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...

All About Your Child - Speech Language Pathology Case History Form

https://www.princeedwardisland.ca/sites/default/files/forms/all_about_your_child_speech_language_pathology_case_history_form.pdf
2021-10-04
Case history for your child to be completed and returned to Speech Language Pathology before your initial appointment.
Speech Language Pathology 161 St. Peter’s Road PO Box 2000 Charlottetown, PE, C1A 7N8 T: 1-844-344-TALK (8255) / F: 902-620-3195 speechandhearing@ihis.org Orthophonie 161 chemin St. Peter’s C.P. 2000 Charlottetown, PE, C1A 7N8 T: 1-...

Adult Speech and Language Pathology Referral Form

https://www.princeedwardisland.ca/sites/default/files/forms/adult_speech_and_language_pathology_referral_form.pdf
2021-10-04
Referral form for Adult Speech Language Pathology.
Adult Speech and Language Pathology Referral Name: Date of Birth: (D/M/Y) Personal Health Number (Provincial Health Card): Home Telephone: Work Telephone: Cell Telephone: Please circle the number we could reach you during the day...

Demande de financement de traitement d’orthodontie pour les patients ayant une fissure palatine

https://www.princeedwardisland.ca/sites/default/files/forms/demande_de_financement_de_traitement_dorthodontie_pour_les_patients_ayant_une_fissure_palatine.pdf
2021-09-02
Veuillez remplir le présent formulaire pour demander un appui financier pour le traitement orthodontique d’une fissure palatine pour les enfants qui naissent avec cette malformation. 
Cleft Palate Orthodontic Treatment Funding program Application Form Please fill out section A and ask the orthodontist or pediatric dentist to fill out section B. If you are applying for additional funding, please complete the declaration and...

Provincial Dental Care Program Application Form

https://www.princeedwardisland.ca/sites/default/files/forms/provincial_dental_care_program_application_form.pdf
2021-09-02
Complete this application to apply for the Provincial Dental Care Program .
Dental Health Services 152 St. Peter’s Road PO Box 2000, Charlottetown, PE C1A 7N8 Provincial Dental Care Program Application Form Telephone 1 (902) 368-5460 Office use only Toll Free 1 (866) 368-5460 Income Verified by: PPLLEEAASSEE...

Self-Isolating Visitor Designation Form

https://www.princeedwardisland.ca/sites/default/files/forms/self-isolating_visitor_designation_form.pdf
2021-08-11
Form to authorize designated compassionate visitors for patients/residents in Health PEI facilities or programs.
Microsoft Word - Self Isolation Visitor Letter.docx 16 Garfield Street 16, rue Garfield PO Box 2000, Charlottetown C.P. 2000, Charlottetown Prince Edward Island Île-du-Prince-Édouard Canada C1A 7N8 Canada C1A 7N8 www....

Plaque Psoriasis Special Authorization Request Form

https://www.princeedwardisland.ca/sites/default/files/forms/anti-tnf_agents_for_psoriasis_special_authorization_request_form.pdf
2021-02-22
Special authorization request form to be completed by your physician or diagnosing specialist.
SPECIAL AUTHORIZATION REQUEST PLAQUE PSORIASIS Fax requests to (902) 368-4905 OR mail requests to PEI Pharmacare, P.O. Box 2000, Charlottetown, PE,...

Programme de financement des pompes à insuline de l’Î.-P.-É. : Formulaire d’évaluation de la contribution du client ou de la famille et de consentement à la divulgation de renseignements

https://www.princeedwardisland.ca/sites/default/files/forms/programme_de_financement_des_pompes_a_insuline_de_li.-p.-e._-_formulaire_devaluation_de_la_contribution_du_client.pdf
2021-01-28
Remplissez ce formulaire pour vous inscrire au Programme de financement des pompes à insuline.  
January, 2021 Page 1 of 6 PEI Insulin Pump Program Client/ Family Contribution Assessment & Release of Information Personal health information...

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