Medical Hyperbaric Oxygen Therapy –
Application to Supervise HBO Therapy
1
Application for Approval – HBOT
APPLICANT INFORMATION (Please Print)
CPSA Registration Number: ____________________________
Last Name: ___________________________________________ Given/First Names: __________________________
Street Address: __________________________________________________________________________________
City: _______________________________________________ Postal Code: ___________________
Telephone Number: (______) ____________________________ Fax Number: (______) ____________________
E-mail Address: _________________________________
P
hysicians supervising HBO therapy shall:
a. H
ave completed at a minimum, a 40-hour course approved by the Undersea & Hyperbaric Medical Society. A
record of completion of the course of training shall be kept on file in the facility;
b. Be certified specialists in anesthesiology or maintain a current certificate in Advanced Cardiac Life Support
(ACLS);
c. Be licensed to practice in Alberta.
1. I have enclosed evidence of:
a. T
raining and competence as listed above.
(Note: This evidence of training and competence is required.) Yes No
b. Current ACLS Yes No
2. E
xpected Practice Start Date: ________________________________________
P
rivacy Notice: The College of Physicians & Surgeons of Alberta collects, uses and/or discloses your person
al
in
formation with your consent or as authorized or required by law and in accordance with our Privacy
Statement. We collect and use your personal information in order to support the business of the College,
specifically protect the public and to guide and regulate our members.
A
pplicant Signature: ________________________________ Date: _____________________________
P
lease return your completed application and required documents (together as one package) to the
College of Physicians & Surgeons of Alberta by fax: 780-428-2712 or by mail:
2700 - 10020 100 ST NW, Edmonton AB T5J 0N3
click to sign
signature
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