Register a New Non-hospital Surgical Accreditation Facility

General facility information

Address(Required)
MM slash DD slash YYYY

Personnel

Medical director name(Required)
Medical director email(Required)

Facility accreditation contact

Identify the individual on your team who will be ultimately responsible for coordinating the assessment logistics. They will be granted access to the secure CPSA Facility Accreditation SharePoint site and will be the primary contact throughout the accreditation process.
Facility accreditation contact name(Required)
Facility accreditation contact email(Required)
Facility Type(Required)
Anesthetic Services(Required)
Scope of procedures(Required)
Please select your sub-specialties from the list below. Note: only the selected scope(s) of procedures will be assessed for facility accreditation

Signature

Checking this box will act as your signature:(Required)
MM slash DD slash YYYY

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