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Update Registration

Update Registration

Forms not submitted in 30 days will be deleted

1Update Registration Information
2Add Machines
3Remove Machines
4Update Machines
5Review
6Sign & Submit

Facility Information

Status Reason

Is this submission related to a violation issued by CDPH-RHB?

Is this submission related to a violation issued by CDPH-RHB? NoIs this submission related to a violation issued by CDPH-RHB? Yes

Type of Facility

Other

Is the facility a mammography provider?

Is the facility a mammography provider? NoIs 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? NoDoes your facility use X-ray machines with energies that exceed 500kVp? Yes

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

Registrant and Address Information

Please complete all data fields in the left column of the form which represents the information currently on file with CDPH-RHB.

Select the update checkbox if you need to provide updated registrant and/or address information to CDPH-RHB.

Update Info

Registrant Name

Updated Registrant Name

Doing Business As (DBA) Name

Updated DBA Name

Business Phone Number

Updated Business Phone Number

Registration Number (FAC)

Click if Registration Number (FAC) is Pending

Physical Address (cannot be P.O. Box)

Update Address

Street

Updated Street

Suite

Updated Suite

City

Updated City

State

Updated State

ZIP Code

Updated ZIP Code

Is mailing address the same as physical address?

Mailing Address

Mailing Street

Mailing City

State

ZIP Code

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