Msqhsurvey

Terms and Conditions

Application For Dental Clinic/Dental Ambulatory Care Center

Facility Profile

Facility name

Corporate ownership

Phone no

Mailing Address

Address

Street

City

State

Postcode

Country

Customer Information (my organisation is listed as below)

Private Dental Clinic

Ambulatory Care Centre - Dental Services

Private Hospital - Dental Clinic

Public Hospital - General Dental Clinic

Public Dental Clinic

Ministry of Defence Dental Clinic

University - General Dental Clinic

Others (Please specify)

Detail of Facility Requesting MSQH Survey

The dental clinic openened in the year:

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.

Number of dental chair cum unit

Number of resident dental practitioners

Number of locum dental practitioners

Number of support staff

The dental clinic has been surveyed previously (if applicable)

First cycle

Number of cycle

Please provide details of major changes in dental chair / unit numbers, extra services etc since last survey (if applicable)

Does dental clinic provide sedation service? What kind of sedation given? (if applicable)

Other relevant information which may help in the allocation of numbers of survey days and surveyors

On behalf of the above facility

Person in charge