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Résultats

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....

Council of the Federation Award for Innovation in Mental Health and Addictions Care Nomination Form

https://www.princeedwardisland.ca/sites/default/files/forms/cofmhaawardnominationform.pdf
2022-04-04
Complete this form to nominate an initiative, project, study or program and associated team for the Council of Federation Award for Innovation in Mental Health and Addictions Care.
Nomination Template: COF MH&A Award Page 1 of 7 Council of the Federation Award for Innovation in Mental Health and Addictions Care Nomination Template Purpose of the Award Mental health and addictions are complex issues that impact many...

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...

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...

Formulaire de demande et de consentement du patient concernant l’aide médicale à mourir

https://www.princeedwardisland.ca/sites/default/files/forms/formulaire_de_demande_et_de_consentement_du_patient_concernant_laide_medicale_a_mourir.pdf
2022-02-08
Ce formulaire de consentement est requis pour participer au processus d’aide médicale à mourir. Les personnes sont encouragées à remplir le formulaire de consentement à l’avance de leur évaluation avec le fournisseur d’aide médicale à mourir. Le consentement peut être retiré ou annulé en tout temps...
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...

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 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...

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