Addition of Spouse

Manitoba Health, Seniors and Long-Term Care

Addition of spouse

Addition of spouse
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

*

Legal middle name

*

Legal last name

*

Please select one

Date of birth

*

Select either English or French as your official language

Current address

Apartment/unit number

*

Street address (or PO box number)

*

City

*

Province

Postal code

*

Is your mailing address the same as your current address?

Mailing address

Apartment/unit number

*

Street address (or PO box number)

*

City

*

Province

Postal code

*

Addition of spouse

Legal first name

*

Legal middle name

*

Legal last name

*

Date of birth

*

Date of marriage

*

Does your spouse already have a Manitoba Health Card?

Please select one:

Specify sex

*

Personal Health Identification Number (PHIN - nine digits)

*

Date of arrival

*

Former country of residence

Select either English or French as your official language

Type of card

Select the type of card

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