Physicians

Administrative Forms

Continued Medical Education (CME) Application Form  ^[PDF]

EMR Users Access Request Form ^[PDF]

Honorarium Form ^[PDF] 

Leave of Absence (LOA) Form ^[PDF] 

Overtime Request Form ^[PDF] 

Signal^© Interim Provider Agreement ^[PDF]

Signal^© Secure Text Messaging App Evaluation Form ^[PDF]

Travel Expense Form ^[PDF] 

Referral Forms

ADHD Program Referral Form ^[PDF]

Adult Immunization Referral Form ^[PDF]

Allergy/Immunology Outpatient Consultation Request ^[PDF]

Chronic Pain Clinic Referral Form ^[WORD]

EMG Referral Request Form (QEH) ^[PDF]

Gynecology Referral Form (Charlottetown) ^[PDF]

Gynecology Referral Form (Summerside) ^[WORD]

Hepatitis C Treatment Program Referral Form (with Patient  Referral Workup) ^[PDF]

Home Care Referral Form ^[PDF]

Immunology/Allergy Outpatient Consultation Request ^[PDF]

Laboratory Services Requisition Forms

Mental Health and Addictions - Adult Referral Form ^[PDF]

Mental Health - Child and Youth Referral Form ^[PDF]

Mental Health and Addictions Out of Province (OOP) Treatment Request for Consideration (Fillable Form) (Printable Form) ^[PDF]

Nephrology Referral Form  ^[WORD]

Oncology Referral Form - PEI Cancer Treatment Centre 

Outpatient Psychiatry Services Referral Form ^[PDF]  Note:  Use your Chrome browser when completing this form.

Palliative Care Program (PIPCP) Client Referral Form ^[PDF]

Pelvic Floor Physiotherapy Referral Form ^[PDF] (PEIPA)  |  Learn about the Pelvic Floor Physiotherapy Program ^[PDF]

PEI Pharmacare Special Authorization Forms for Medical Professionals

Pre-Operative Stoma Site Marking ^[PDF]

Provincial Ambulatory Care Referral Form  ^[PDF]

Provincial Geriatric Program Referral Form ^[PDF]  |  Learn about the Dementia Specialty Team ^[PDF]

Provincial Medical Assistance in Dying (MAiD) Clinic Referral and Intake Form ^[PDF]

Provincial Nurse Specialized in Wound, Ostomy, Continence Referral Form ^[PDF]

Provincial Obstetrical Referral Form ^[PDF]

Provincial Palliative Care Centre Application for Admission Form ^[PDF]

Respirology Referral Form (Moncton) ^[PDF]

Strength Program Referral Form Package ^[PDF]