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

NOTE: If you are already registered with TPP Alberta, you do not have to complete this form to re-order pads.

Registrant information

Name (as to appear on the pad):*

First Middle inital(s) Last

Profession:*

Physician
Dentist
Veterinarian
Nurse Practitioner
Podiatric Physician

Regulatory Authority License/Registration #*

Locum practitioner?*

(If yes, no address will appear on the secure TPP pad)

No
Yes

Contact phone #:*

Preferred method of correspondence:*

Hard copy mail
Email

Information for TPP pad

Clinic name printed on pad*

Address printed on pad:*

Street Address City Postal code

Phone # printed on pad:*

Shipping information

Pad delivery address:*

(NOTE: NO PO BOXES or OUT OF PROVINCE addresses allowed)

Street Address City Postal code

Phone number for delivery location:*

Signature

Checking this box will act as your signature:

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

Email*

*Physicians: please use CPSA verified email

Enter Email Confirm Email

Date (should be typed in the format mm/dd/yyyy, as in 03/15/2023)*

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 TPPinfo@cpsa.ab.ca, 780-969-4939 or toll-free at 1-800-561-3899.

Email

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

Registrant information

Information for TPP pad

Shipping information

Signature

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