Dental X-ray Registration Form

MANITOBA HEALTH
REGISTRATION OF DENTAL X-RAY EQUIPMENT

 

THE REGISTRATION OF THIS EQUIPMENT DOES NOT IMPLY APPROVAL FOR ITS OPERATION.

1. Name and Contact Information of Dental Unit Owner
Name:*
Street and Number:*
City/Town:*Province:Manitoba
Postal Code:*  
Phone:* - -   
 
E-Mail*:  
Re-type E-Mail*:  
 
2. Location of Dental Unit, if different from above
Business Name:
Street and Number:
City/Town:Province:Manitoba
Postal Code:  
Phone: - -   
 
E-Mail:  
Re-type E-Mail:  
 
3. Type of Dental Unit*
Intra-oral
Panoramic
Cephelametric
Computerized Tomographic Cone Beam
 
4. Medical Device License #
In contrast to licensed devices, unlicensed devices have not undergone any assessment by Health Canada as to their safety, quality or effectiveness. Facilities who import and purchase unlicensed devices may place the health and safety of their staff and patients at risk.
Please Note: Health Canada requires that X-ray equipment have an active Medical Device Licence. If you need assistance please contact Health Canada, Medical Devices, Health Products and Food Branch Inspectorate at 204-984-1341 or e-mail: ms-med@hc-sc.gc.ca
 
5. Is this machine replacing an existing unit?*
Yes
No
If YES, provide previous registration information on the unit being replaced. This information may be found on a gold label with the name of CancerCare Manitoba or Manitoba Cancer Treatment and Research Foundation, X-ray equipment registration No. The label will have UD-000 or RD-000 designation.
Make of Replaced Unit:
Model:
Radiation Protection 
Registration Number:
- (Example: UD-234A or UD-234AB)
 
6. New x-ray equipment information
Manufacturer:*
Model Name:*
Model Number
(if applicable):
Generator S/N:*
Tube S/N:*
Supplier:*
Date (dd/mm/yyyy)
of Manufacture:*

 
7. Facility Appointed Radiation Safety Person/Contact Person
Name:*
Title:*
Phone:* - -   
 
E-Mail*:  
Re-type E-Mail*:  
 
Date (dd/mm/yyyy):*
 
* Required field 

    
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