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This form is used to apply for approval of a practice setting where physiotherapy services may be delivered.
47
Questions
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1
Name of Practice Setting
*
This field is required.
Name of Practice Setting
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2
Practice Setting Address
*
This field is required.
Street Address
Street Address Line 2
City
Province
Postal Code
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
Practice Setting Phone Number
*
This field is required.
Please enter a valid phone number.
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4
Practice Setting Email
*
This field is required.
example@example.com
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5
Website Address
*
This field is required.
www.example.com
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6
Facebook
*
This field is required.
If no Facebook page enter Not Applicable.
Facebook Page
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7
Twitter
*
This field is required.
If no Twitter handle enter Not Applicable.
Twitter Handle
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8
LinkedIn
*
This field is required.
If no LinkedIn profile enter Not Applicable.
LinkedIn Profile
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9
Instagram
*
This field is required.
If no Instagram handle enter Not Applicable.
Instagram Handle
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10
TikTok
*
This field is required.
If no TikTok account enter Not Applicable.
TikTok Account
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11
YouTube
*
This field is required.
If no YouTube account enter Not Applicable.
YouTube Account
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12
Do you have additional social media accounts to report?
*
This field is required.
YES
NO
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13
Additional Social Media Accounts
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14
Designated Owner's Name
*
This field is required.
For the purpose of this application and any authorization granted, the "designated" owner is the contact person between the College of Physiotherapists of Alberta and the owner(s) of the practice setting. The designated owner needs to be knowledgeable of the regulatory responsibilities of registered physiotherapists and familiar with physiotherapy-related business operations.
First Name
Last Name
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15
Designated Owner's Phone Number
*
This field is required.
Please enter a valid phone number.
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16
Designated Owner's Email
*
This field is required.
example@example.com
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17
File Upload: Certificate of Completion
*
This field is required.
Provision of Professional Services Module. Designated Owner's certificate of completion dated
within the last two years.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Only PDF documents are accepted.
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18
You must provide the name of each practice setting owner. Do you have another owner to include in this application?
*
This field is required.
YES
NO
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19
Owner's Name
First Name
Last Name
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20
You must provide the name of each practice setting owner. Do you have another owner to include in this application?
YES
NO
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21
Owner's Name
First Name
Last Name
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22
Most Responsible Physiotherapist's Name
*
This field is required.
First Name
Last Name
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23
Most Responsible Physiotherapist's Registration Number
*
This field is required.
Registration number assigned by the College of Physiotherapists of Alberta
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24
Most Responsible Physiotherapist's Email
*
This field is required.
A copy of this application, once submitted, will be emailed to the Most Responsible Physiotherapist at the email address below so they are aware of the application status.
example@example.com
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25
File Upload: Agreement
*
This field is required.
Most Responsible Physiotherapist's signed Provision of Professional Service Agreement.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Only PDF documents are accepted.
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26
File Upload: Certificate of Completion
*
This field is required.
Provision of Professional Services Module. Most Responsible Physiotherapist's certificate of completion dated
within the last two years
.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Only PDF documents are accepted.
Cancel
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27
File Upload: Contract
*
This field is required.
Sample contract between physiotherapy staff and practice setting.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Only PDF documents are accepted. One document per file upload.
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28
File Upload: Privacy Statement
*
This field is required.
Practice setting privacy statement.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Only PDF documents are accepted. One document per file upload.
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29
File Upload: Fees
*
This field is required.
Fee guideline or schedule.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Only PDF documents are accepted. One document per file upload.
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30
File Upload: Patient Safety
*
This field is required.
Patient safety incident management plans.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Only PDF documents are accepted. One document per file upload.
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31
File Upload: Privacy Safeguards and Records Management
*
This field is required.
Operational policies related to privacy safeguards and records management.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Only PDF documents are accepted. One document per file upload.
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32
File Upload: Infection Prevention and Control
*
This field is required.
Operational policies related to infection prevention and control.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Only PDF documents are accepted. One document per file upload.
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33
File Upload: Privacy Impact Assessment
Include if practice setting has completed a Privacy Impact Assessment.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Only PDF documents are accepted. One document per file upload.
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34
File Upload: Unregulated Health Providers
Operational policies regarding the use of unregulated health providers to deliver physiotherapy services if applicable. MUST include if practice setting employs support workers in the delivery of physiotherapy services.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Only PDF documents are accepted. One document per file upload.
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35
As the Designated Owner, I agree to:
*
This field is required.
Positively enable the Most Responsible Physiotherapist and any other physiotherapists working at the practice setting named in this application to meet their professional responsibilities established in the College of Physiotherapists of Alberta's Standards of Practice, Code of Ethical Conduct and governing legislation.
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36
As the Designated Owner, I agree to:
*
This field is required.
Positively enable the Most Responsible Physiotherapist to fulfil their obligations in the Provision of Service Agreement.
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37
As the Designated Owner, I agree to:
*
This field is required.
Immediately inform the College of Physiotherapists of Alberta if the Most Responsible Physiotherapist named in this application ceases to be the most responsible physiotherapist at this practice setting.
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38
As the Designated Owner, I agree to:
*
This field is required.
Within 30 days of the Most Responsible Physiotherapist's resignation, submit a Change of Most Responsible Physiotherapist Application to the College of Physiotherapists of Alberta.
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39
As the Designated Owner, I agree to:
*
This field is required.
Advise the College of Physiotherapists of Alberta of any and all changes to the information collected on this application either before or after approval, including but not limited to a change of ownership or Designated Owner.
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40
As the Designated Owner, I agree to:
*
This field is required.
Only include the term 'physiotherapy’ or variants thereof in the practice setting name, if a physiotherapist is providing services in the practice setting. In accordance with the Health Professions Act, section 128(1), physiotherapy will be removed from the practice setting name within 90 days if no physiotherapist is providing services in the practice setting.
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41
As the Designated Owner, I understand that:
*
This field is required.
The College of Physiotherapists of Alberta may withdraw an approval granted if any of the above conditions are not met.
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42
As the Designated Owner, I certify and declare that:
*
This field is required.
The information provided on this application is true.
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43
Is this an initial application for the owners listed on this application?
*
This field is required.
YES
NO
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44
Payment Options
*
This field is required.
You may pay the application fee by MasterCard, Visa or cheque. If paying by cheque, payment must be received before staff will start to review this application.
Are you paying the application fee by MasterCard or Visa?
YES
NO
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45
My Order
Non-refundable application fee. Instructions: Creating an order is a two-step process. (1) Add (+), and then (2) select "Add to Bag". Select "Next" after these two steps to proceed to the payment page.
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Great Product Name
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ORDER SUMMARY
Total cost
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Application Fee
Non-refundable application fee for approval of practice setting (non-regulated owner)
$
2,500.00
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First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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46
Submission Date
*
This field is required.
-
Date
Year
Month
Day
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47
Designated Owner's Signature
*
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