Sleep Medicine Diagnostics - Register a new facility - College of Physicians & Surgeons of Alberta

Personnel

Medical Director

Name*

First Last

Registration Number*

Level of Approval for Directing*

Check all current levels of approval.

Level 1: Adult Comprehensive Polysomnography
Level 1: Adult Complex Respiratory Patients
Level 1: Pediatric Comprehensive Polysomnography
Level 1: Pediatric Complex Respiratory Patients
Level 2: Adult Unattended Polysomnography
Level 3: Adult Home Sleep Apnea Testing

Level of Approval for Interpreting

Check all current levels of approval.

Level 1: Adult Comprehensive Polysomnography
Level 1: Adult Complex Respiratory Patients
Level 1: Pediatric Comprehensive Polysomnography
Level 1: Pediatric Complex Respiratory Patients
Level 2: Adult Unattended Polysomnography
Level 3: Adult Home Sleep Apnea Testing

Address for correspondence*

Street Address Address Line 2 City Province ZIP / Postal Code

Phone*

Email*

Enter Email Confirm Email

Interpreters*

Please list all of the physicians who will be interpreting test results at this facility. Click the + to add additional rows.

Name	CPSA Registration Number	Level of Approval (Level 1 (Adult PSG, Adult Complex Respiratory, Pediatric PSG, Pediatric Complex Respiratory), Level 2 and/or Level 3)

Supervisor/Manager

Name*

First Last

Phone*

Email*

Enter Email Confirm Email

Qualifications*

Financial Contact

Name*

First Last

Address for correspondence*

Street Address Address Line 2 City Province ZIP / Postal Code

Phone*

Email*

Enter Email Confirm Email

Sleep Medicine Diagnostics – Register a new facility

Step 1 of 4

General Facility Information

Personnel

Medical Director

Supervisor/Manager

Financial Contact

Testing: Sleep Medicine Procedures

Attended Polysomnography (Level 1)

Level 2

Level 3

Titration

Medical Director's Signature

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