Registration Address Form - College of Physicians & Surgeons of Alberta

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
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:*
DD slash MM 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:*
DD slash MM slash YYYY
Will you be accepting new patients?*
- Yes
- No
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Admin
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QUEST Library
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Document Type
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Document Name
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Issuer
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Recipient
Comments
This field is for validation purposes and should be left unchanged.

Address designation