Diagnostic Laboratory - Register a New Facility Form - College of Physicians & Surgeons of Alberta

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This field is for validation purposes and should be left unchanged.
General Facility Information
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CPSA Facility Number
For CPSA use only.
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Facility Type
For CPSA use only.
Facility Name*
Address*
Street Address Address Line 2 (Optional) City Province Postal Code
Phone Number*
Facility Ownership/Funding Type*
- Public
- Private
Expected Opening Date/Commencement of Patient Testing (dates should be typed in the format mm/dd/yyyy, as in 03/15/2023)*
MM slash DD slash YYYY
Does the laboratory intend to perform tests that are intended for diagnosis, prevention or monitoring the treatment of health issues by primary care providers or specialists?
- Yes
- No
- Unsure
Does the laboratory intend to perform tests that are intended for diagnosis, prevention or monitoring the treatment of health issues in a direct-to-consumer funding model?
- Yes
- No
- Unsure
Does the laboratory intend to perform tests that are intended for wellness which are not considered medically necessary (for most clients) in a direct-to-consumer funding model?
- Yes
- No
- Unsure
What groups will receive your laboratory services? (check all that apply)
- Directly to the public within Alberta
- Directly to the public, from outside Alberta
- Primary care providers in Alberta (patient testing for medical purposes)
- Specialists in Alberta (patient testing for medical purposes)
- Other laboratories in Alberta
- Other laboratories outside Alberta
- Other
If other, please specify.
Will your laboratory perform the analysis on location?
- Yes
- No, referred to our laboratory at another location
- No, referred to another laboratory in Alberta
- No, referred to another laboratory in Canada
- No, refered to another laboratory outside Canada
- Other
If other, please specify.
Will your laboratory perform phlebotomy?
- Yes
- No
Please provide details.
Do you offer mobile services (i.e. do staff travel off site to provide services)?
- Yes
- No
Please provide details.
What are the routine hours of operation?*
If hours of operation vary throughout the week, please click the + to add additional rows.
Day Hours
Are staff readily available outside of routine hours (on–call)?*
- Yes
- No

Diagnostic Laboratory - Register a New Facility

Note: Facilities that are not reporting results for patient management and only doing direct-to-consumer wellness testing (for clients) do not require accreditation.

Step 1 of 5

General Facility Information

Personnel

Please indicate the following as full-time equivalents:

Scope of Examinations

Required Documentation for Submission

Signature

Submitter Information

Appendix A

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