Notification Form for Changing a Practice Name: The Alberta College of Dental Hygienists

The below form is a requirement for dental hygienists who are changing the name of a practice they own or operate.

As per College Bylaws:

At least 90 days prior to opening, operating, acquiring, adding a component to, or moving a dental hygiene practice, a regulated member is required to provide written notification to the College of the following information:

(a) the practice name;
(b) phone number;
(c) email address;
(d) complete business address;
(e) names of any additional owners;
(f) any other information requested by the Registrar.

A regulated member is required to provide written notification to the College of any change in the ownership interests or changes to information listed in (1) above at least 90 days prior to the anticipated change.

Please complete and submit this form.

First Name of Owner/Operator *

Last Name of Owner/Operator *

Registration Number of Owner/Operator *

Email address (must match your email address in the registrant portal) *

This will be the email address we use to communicate with you about your dental hygiene practice.

Phone Number (must match your phone number in the registrant portal) *

Is there more than one owner/operator of this practice? *

Yes

If you responded Yes to the above question, please provide full name(s) and registration number(s), if applicable. Any additional business owners/operators who are registered dental hygienists must complete this form in full and submit it separately.

Additional Owners/Operators

Existing name of dental hygiene practice *

New name of dental hygiene practice *

Anticipated date of the name change *

Leave Blank

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Notification Form for Changing a Practice Name

Can’t find what you’re looking for?