TPP Alberta | TPP Prescribers Registration Form - College of Physicians & Surgeons of Alberta

Name

This field is for validation purposes and should be left unchanged.

Registrant information

Name (as to appear on the pad)*

First Middle inital(s) Last

Email*

Enter Email Confirm Email

Profession*

Regulatory Authority License/Registration number*

Contact phone number*

Information printed on pad

Would you like the clinic name and address printed on your TPP pad?*

Yes
No

PLEASE NOTE: If you choose not to have a clinic address printed on your TPP pad, you will be responsible for adding the required clinic information to the prescription at the time of prescribing. This includes locuming at multiple locations.

Clinic name printed on pad*

Clinic address printed on pad*

Clinic phone number printed on pad*

Shipping information

Shipping address*

ATTENTION: NO PO BOXES or OUT OF PROVINCE addresses allowed. Residential addresses will be verified by your regulatory body. A signature is required at time of delivery.

Shipping address*

ATTENTION: NO PO BOXES or OUT OF PROVINCE addresses allowed. Residential addresses will be verified by your regulatory body. A signature is required at time of delivery.

Same as clinic address

Shipping address contact phone number

If the shipping address is different from the clinic address, please enter a different phone number.

Signature

Checking this box will confirm you have read the TPP Program Guide*

I confirm I have reviewed and understand the content in the TPP Program Guide.

Checking this box will act as your signature*

I confirm I am the registrant and that information in this form is accurate.

Special instructions

We collect and share the personal information in this form for the purposes of registering you in TPP Alberta. We may share your information with the printing and courier vendors for the purpose of producing the secure pads, OR with regulatory organizations as set out in CPSA Bylaws for TPP Alberta. If you have any questions about collecting your information, please contact TPP Alberta at TPP.info@cpsa.ab.ca, 780-969-4939 or toll-free at 1-800-561-3899.

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Profession*

Physician
Dentist
Veterinarian
Nurse Practitioner
Podiatric Physician

Registrant information

Information printed on pad

Shipping information

Signature

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