Physician Extender - Surgical Assistant Form

Before starting this form, make sure you have the following document:

Completed and witnessed Registration Understanding Acknowledgment

  • Important

    You must complete and submit this form at least 30 days before your expected start date. Please see information on our website under Fees and Start Date before selecting a registration date.
  • DD dash MM dash YYYY
    We will make every effort to complete your registration by this date. Note: We cannot issue a backdated practice permit.
  • Applicant information

  • Current contact information

    (for internal CPSA use only)
  • Additional information required

  • Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
    Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 5 MB.
  • Attached documents must be: jpeg, png, jpg, tiff or pdf. Please do not password protect your files.
    Accepted file types: jpeg, png, jpg, tiff, pdf, Max. file size: 5 MB.
  • Signature

    Please keep a copy of all documents for your records, and allow 30 days for processing this application. Note: We cannot guarantee a practice permit will be issued.
  • DD dash MM dash YYYY
  • After clicking "Submit", you will be redirected to CPSA's Secure Payment Processing Portal to complete your payment. We require payment to begin processing your request.

    After completing payment, we will email you a receipt. That receipt is confirmation that your information was received and your request will be processed. Note: We cannot guarantee a practice permit will be issued.
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    Admin fields

    For CPSA use only
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    Please enter a number from 1 to 1.
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CPSA acknowledges we are on traditional lands of First Nations and Métis people. Through our work, we strive to respect, honour and celebrate the histories, languages and cultures of First Nations, Métis, Inuit and all First Peoples of Canada.