Service Providers Family Member

Legal first name as it appears on the Manitoba health card

Legal last name as it appears on the Manitoba health card

Date de naissance

Relationship to the primary applicant

Is the family member registered with Manitoba health?

Numero d'immatriculation (six-chiffres alphanumériques)

Numéro d’identification personnel (NIP - neuf chiffres)

Mother's first name as it appears on the Manitoba health card

Mother's last name as it appears on the Manitoba health card

Mother's date of birth

Is the family member currently registered in another province/territory?

Specify another province/territory

Date of arrival in Manitoba