Registration Address Form - College of Physicians & Surgeons of Alberta

Instructions:

Fully completing this form will facilitate your registration. To assist CPSA in contacting you, please complete all required fields and provide at least one phone number. This phone number can be a public or private business number, a private home number or a cell phone number.

Name*
First Last
CPSA Registration #*
Email*
Enter Email Confirm Email
Phone #*
Have you previously registered with CPSA under a different name?*
- Yes
- No
Previously registered name*
First Last Initials
Address designation
In accordance with the Health Professions Act, please identify which address you want publicly released and published on CPSA’s website.
Which address would you like published and publicly visible on CPSA's website?*
- Business address
- Other address
To which address would you like your CPSA mail sent?*
- Business address
- Other address
Business address:*
If you selected "clinic address" as the address to be publicly visible on the website, this address will be published.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Business phone # (public)*
Business fax # (public)*
Effective date (should be typed in the format mm/dd/yyyy, as in 03/15/2023):*
MM slash DD slash YYYY
Other address:*
If you selected "other address" as the address to be publicly visible on the website, this address will be published.

Street Address Address Line 2 City Province Postal Code
Other phone #*
Other fax #*
Effective date (should be typed in the format mm/dd/yyyy, as in 03/15/2023):*
MM slash DD slash YYYY
Hidden
Will you be accepting new patients?*
- Yes
- No
Hidden
Admin
Hidden
QUEST Library
Hidden
Document Type
Hidden
Document Name
Hidden
Issuer
Hidden
Recipient
Email
This field is for validation purposes and should be left unchanged.

If you have questions, please contact CPSA by email at registration@cpsa.ab.ca, or call us at 780-969-4924 or toll-free at 1-800-320-8624 ext. 4924 (Alberta only).

Instructions:

Address designation

Admin

CPSA's 2023 annual report is now available