College of Physicians and Surgeons of British Columbia300–669 Howe Street Vancouver BC V6C 0B4 www.cpsbc.ca

Telephone: 604-733-7758 Toll Free: 1-800-461-3008 (in BC) Fax: 604-733-3503

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NON-HOSPITAL MEDICAL AND SURGICAL FACILITIES ACCREDITATION PROGRAM

Approved by NHMSFP Committee March 2009 Updated December 2017

Appropriate Procedures ListHAIR TRANSPLANT

Physician name: CPSID:

Facility applying to:

Please indicate only the procedures you wish to perform at the above-mentioned facility. The facility must be currently approved for a hair transplant program, or the medical directory must submit a Proposal for New/Experimental Procedure form.

Hair transplantationFollicular unit graftingRoboticOther:

I hereby certify that the procedures selected in this application are within the scope of my current practice.

Physician signature: Date: