Addition of minor child

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Manitoba Health, Seniors and Long-Term Care

Addition of minor child

Add minor child
Supporting documentation

Cardholder's information

Registration number (six-digit alphanumeric)

*

Personal Health Identification Number (PHIN - nine digits)

*

Primary phone number

*

Email address

*

Can we contact you at this email address?

Legal first name

*

Do you have a middle name?

Legal middle name

*

Legal last name

*

Sex

Date of birth

*

Select either English or French as your official language

Current address

Street address (or PO box number)

*

City

*

Province

Postal code

*

Is your mailing address the same as your current address?

Mailing address

Street address (or PO box number)

*

City

*

Province

Postal code

*

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