Withdraw Facility Registration

Forms not submitted in 30 days will be deleted

Status Reason

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

NoYes

Type of Facility

Other (please specify)

Is the facility a mammography provider?

NoYes

Does your facility use X-ray machines with energies that exceed 500kVp?

NoYes

Ownership Change

This should be an individual that a Radiologic Health Branch representative may contact regarding any information provided on this form.

First Name

Last Name

Email Address

Phone Number

Registrant Name

Enter the name of the facility, business, or practice.

Doing Business As (DBA) Name

Business Phone Number

Registration Number (FAC)

This number can be found on your registration confirmation letter or Certificate of Registration

Click if Registration Number (FAC) is Pending

Street

Suite Number

City

State

ZIP Code

Is mailing address the same as physical address?

Street

City

State

ZIP Code