Register Class 3B & 4 Lasers

Company
This field is for validation purposes and should be left unchanged.
Owner information
Owner name:
First Last
Address:
Street Address City Postal Code
Phone:
Fax:
Email:
Facility information
Facility name:
Facility address:
Street Address City Postal Code
Phone:
Fax:
Contacts
Physician contact(s);
Name Email Owner? (Yes/No) Uses? (Yes/No)

Click the + button to add an additional physician.
Administrative/Management contacts;
Name Email Position

Click the + button to add an additional individuals.
Equipment details
Type of laser:
- Class 3b laser
- Class 4 laser
Manufacturer:
Manufacturer date (should be typed in the format mm/dd/yyyy, as in 03/15/2023):
MM slash DD slash YYYY
Model #:
Serial #:
Location of equipment in facility:
Primary purpose of laser:
- Cardiology
- Dental
- Dermatology
- Obs/Gynecology
- Oncology
- Ophthalmology
- Physiotherapy
- Podiatry
- Radiology
- Research
- Surgery
Signature
Checking this box will act as your signature:*
- I confirm the information in this application is complete and accurate, and that the equipment and facility comply with the Occupational Health and Safety Code.
Name of Facility owner:*
Email*
This is the email address we will send a submission confirmation notification to.
Enter Email Confirm Email
Date (should be typed in the format mm/dd/yyyy, as in 03/15/2023)*
MM slash DD slash YYYY
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Name	Email	Owner? (Yes/No)	Uses? (Yes/No)

Name	Email	Position

Owner information

Facility information

Contacts

Equipment details

Signature

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