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*
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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
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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

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

Pulmonary Function Diagnostics – Register a new facility

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