Application For Chronic Dialysis

Facility Profile

Mailing Address

Customer Information (my organisation is listed as below)

Detail of Facility Requesting MSQH Survey
and currently has the following number of dialysis stations where applicable (Please specify number in each type). Please note all dialysis stations must be declaed. Should there be any changes prior to the survey, contact the MSQH as soon as possible.

The chronic dialysis centre has been surveyed previously (if applicable)

Number of staff:

Please provide the following details separately as applicable:

On behalf of the above facility