Laser Transfer of Ownership Form Laser Renewal Form Name(s) of Registered Owner(s):(Required)PrefixFirst NameLast Name Add RemoveTo add more rows, click the blue plus sign to the right of the field. Equipment Location:(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Untitled(Required)Treatment room # or name:Equipment InformationType of Equipment (e.g., CO2, Nd: YAG, InGaAs, etc.):(Required)Untitled(Required) Class 3b Class 4 Is the beam path fully enclosed?(Required) Yes No Manufacturer:(Required)Manufacture Date:(Required) MM slash DD slash YYYY Model:(Required)Equipment Type:(Required) Stationary Mobile Serial Number (Base):(Required)Serial Number (Probe):(Required)Status:(Required) Active *Inactive *If your facility has been decommissioned, you must deregister it. Go to Member Resources → Modalities → Laser on the member’s side of theccoa.ca to download and complete the Laser Deregistration Package.*Date Inactive:(Required) MM slash DD slash YYYY Declaration I, Name(Required) First Last solemnly declare that:the information contained in this form is complete and accurate. I have completed a laser training course and I am competent in the use of laser equipment. I acknowledge the following: I have pre-operation and post-operation checklists established. I have proper signage that is prominently displayed when the laser is in use at all access points to the laser room. The signage is removed each time the laser treatment has ended. My laser is in safe working order and is operated in a room where there is consideration for the risk of accidental exposure to any person. I am aware that laser treatment delivery must be provided by only the chiropractor or appropriately trained staff members, as per CCOA Standard of Practice 4.2 Assignment of Clinical Duties (see “Activities that may be assigned,” point 4). I will operate this laser only within the scope of practice as authorized by the College of Chiropractors of Alberta. Owner Signature(Required)Date Signed(Required) MM slash DD slash YYYY Questions? Please feel free to contact registration@theccoa.ca.
