Pulmonary Function Diagnostics - Register a new facility - College of Physicians & Surgeons of Alberta

General Facility Information
Facility Name*
Owner(s)*
Address*
Street Address Address Line 2 City Province ZIP / Postal Code
Phone*
Fax
Email*
Enter Email Confirm Email
Please indicate the highest level of testing that will be performed in your facility:*
- Level II
- Level III
- Level IV

Personnel
Medical Director
Name*
First Last
Registration Number*
Current level of approval for directing*
- Level II
- Level III
- Level IV
Current level of approval for interpretation
- Level II
- Level III
- Level IV
Address for correspondence*
Street Address Address Line 2 City Province ZIP / Postal Code
Phone*
Email*
Enter Email Confirm Email
Interpreters
Interpreters*
Please list all of the physicians who will be interpreting test results at this facility. Click the + to add additional rows.
Name CPSA Registration Number Highest Level of Approval to Interpret (Level II, III or IV)
Blood Gas Consultant
If this section does not apply to your facility, please leave it blank.
Name
First Last
Registration Number
Phone
Email
Enter Email Confirm Email
Supervisor/Facility Manager
Name*
First Last
Phone*
Email*
Enter Email Confirm Email
Qualifications*
Financial Contact
Name*
First Last
Address for correspondence*
Street Address Address Line 2 City Province ZIP / Postal Code
Phone*
Email*
Enter Email Confirm Email

Does your facility have access to send Electronic Medical Records to Netcare?
- Have access
- Have applied/in progress
- Have not applied

Facility Equipment*
Dates should be typed in the format mm/dd/yyyy, as in 03/15/2023.
Equipment Model Serial Number Date purchased (mm/dd/yyyy)

Medical Director's Signature
Medical Director's Name*
First Last
Date (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023)*
MM slash DD slash YYYY
Checking this box will act as your signature:*
I have reviewed the information in this form and confirm it is accurate.
Privacy Notice: This information is being requested under the authority provided by Section 8.2(3) of Schedule 21 of the Health Professions Act. CPSA collects, uses and/or discloses your personal information with your consent or as authorized or required by law and in accordance with our Privacy Statement. We collect and use your personal information in order to support the business of CPSA, specifically to protect the public and guide and regulate our members.
Email
This field is for validation purposes and should be left unchanged.

Pulmonary Function Diagnostics – Register a new facility

Name	CPSA Registration Number	Highest Level of Approval to Interpret (Level II, III or IV)

Equipment	Model	Serial Number	Date purchased (mm/dd/yyyy)