Application For Dental Clinic/Dental Ambulatory Care Center

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 dental chair cum unit, dental practitioners and support staff. Please note all the dental chairs must be declared. Should there be any changes prior to the survey, contact the MSQH as soon as possible.

The dental clinic has been surveyed previously (if applicable)

On behalf of the above facility