Laser Request form

All Class 2 and higher laser-producing instruments must be registered (see laser classes for more information). Please complete the following form to complete the registration process:

Instrument Information

Serial Number: 
Manufacturer:
Model:
Description of Instrument:
Class:
Description of Instruments Use:
Emission Duration: Continuous  Pulse
Fixed or Mobile: Fixed  Mobile
Power Output:
Wavelength:
Used with patients: Yes  No

Location Information

Building:  
Room Number:  
Responsible Person:
Contact Person:
Contact Phone Number:
Contact Email Address:
Additional Comments/Questions: