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New Facility Registration
New Facility Registration
Tutorial
1
New Facility
2
Machine Inventory
3
Review
4
Sign & Submit
Use this form only when both of the following conditions are met:
Your facility, business, or practice possesses one or more radiation machines; and
Your facility, business, or practice does not already have a registration number issued by the
California Department of Public Health, Radiologic Health Branch (CDPH-RHB)
Facility Information
Status Reason
Is this submission related to a violation issued by CDPH?
Is this submission related to a violation issued by CDPH?
No
Is this submission related to a violation issued by CDPH?
Yes
Type of Facility
Human Medical
Human Dental
Veterinary
Industrial
Schools/Colleges/Universities
Other
Other (please specify)
Is the facility a mammography provider?
Is the facility a mammography provider?
No
Is the facility a mammography provider?
Yes
Does your facility use X-ray machines with energies that exceed 500kVp?
Does your facility use X-ray machines with energies that exceed 500kVp?
No
Does your facility use X-ray machines with energies that exceed 500kVp?
Yes
Ownership Change
New Owner
Former Owner
Facility Contact Information
This should be an individual that a CDPH-RHB representative may contact regarding any information provided on this form.
First Name
Last Name
Email Address
Phone Number
Registrant Information
Registrant Name
Enter the name of the facility, business, or practice.
Doing Business As (DBA) Name
Business Phone Number
Registration Number (FAC)
Click if Registration Number (FAC) is Pending
Physical Address (cannot be P.O. Box)
Street
Suite Number
City
State
California
Alabama
Alaska
Arizona
Arkansas
Colorado
Connecticut
Deleware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code
Is mailing address the same as physical address?
Mailing Address
Street
City
State
California
Alabama
Alaska
Arizona
Arkansas
Colorado
Connecticut
Deleware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code