Laser Registration Application Laser Registration Application Application for Laser Equipment RegistrationApplication Type(Required) New Laser Transfer of Ownership Modification to Equipment Temporary/trial Relocation Renovation If you selected 'Temporary/Trial', indicate the date the trial ends: MM slash DD slash YYYY Owner Name:(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Owner Phone Number:(Required)Clinic Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Treatment room number or name:(Required)Where is the laser used?Equipment DescriptionClass:(Required) 3b 4 Equipment Type(Required) Stationary Mobile Manufacturer:(Required)Manufacture Date:(Required) MM slash DD slash YYYY Model:(Required)Serial Number (base):(Required)Type fo Laser (e.g., CO2, Nd: YAG, InGaAs, etc.)(Required)Is beam path fully enclosed?(Required) Yes No DeclarationI,Name(Required) First Last , solemnly declare that: that I have completed a laser training course and I am competent in the use of laser equipment. I acknowledge the following: 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 have pre-operation and post-operation checklists established. I am aware that laser treatment delivery must be provided by only the chiropractor or appropriately trained staff members, as per 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. I certify that the information contained in this application is complete and accurate. Signature of CCOA Registered Owner:(Required)Date Signed:(Required) MM slash DD slash YYYY Questions? Please feel free to contact registration@theccoa.ca.
