Laser Equipment Additional Facility Application Form - College of Physicians & Surgeons of Alberta

IMPORTANT
Only complete this form if a laser is used in more than one facility. You will have to complete and submit a separate Compliance Verification Report for each additional facility.

1. Additional Facility information

Facility name:

Contact name:

First Last

Facility address:

Street Address City Postal Code

Phone:

Fax:

Email:

Enter Email Confirm Email

Please indicate area of practice where the equipment is located:

Click to add another additional facility where this equipment will be used:

Add second facility

2. Additional Facility information

Facility name:

Contact name:

First Last

Facility address:

Street Address City Postal Code

Phone:

Fax:

Email:

Please indicate area of practice where the equipment is located:

Additional documents

A completed compliance report is necessary for review and for registration of additional facilities.

Upload completed compliance report:

Signature

Checking this box will act as your signature:*

I confirm I am the facility owner and that the information in this application is complete and accurate. I also confirm the equipment and facility comply with the Radiation Protection Act and Regulation.

Name of Facility owner:*

Email*

This is the email address we will send a submission confirmation notification to.

Enter Email Confirm Email

Date*

Your privacy is important to us! We collect, use and/or disclose your personal information with your consent unless otherwise authorized or required by legislation. As per our CPSA Privacy Statement, we collect and use your personal information to do our CPSA work, which is to protect Albertans and to guide and regulate Alberta physicians.

1. Additional Facility information

2. Additional Facility information

Additional documents

Signature

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