ADA Private Dental Registration

Private Dental Practice Details

Practice name *

Trading name *

Practice ABN *

Practice owner's name *

Prefix

First Name

Last Name

Is the practice owner an ADA member? *

Is this practice part of a corporate group? *

Practice street address *

Address Line 1

Address Line 2

City

State

Postcode

Does the practice have a different postal address? *

Yes – different postal address No – same as street address

Practice phone number *

Practice fax number

Practice email *

Preferred accreditation contact name *

Prefix

First Name

Last Name

Preferred accreditation contact position *

Preferred accreditation contact phone *

Preferred accreditation contact email *

Preferred contact method

Practice web address

Assessment

Select Assessment Type *

QIP Private Dental Fees

Initial Practice Fee for ADA Members: A private practice must have at least one (1) full fee paying ADA Member working at each registered practice site to be eligible to access the discounted ADA Member fee for re-accreditation.
Multiple Practice Discount: A discount of 15% will apply when you register more than one practice.
Outreach Location: Where dental services are provided at an independent outreach location operating less than 20 hours per month, an additional site certificate fee of $110 (inc GST) per site applies.

Client Services Agreement: Click here to download a copy of the QIP Private Dental Client Services Agreement.

Do you have any additional practices (operating more than 20 hours per month with the same management systems) that you would like to register? *

Do you have any outreach locations (operating less than 20 hours per month) that you would like to register? *

Review & Submission

Total Fee (inc GST)

A$2,200.00

Desktop Assessment

1 main site

Practice Details

Practice Name—

Trading Name—

ABN—

Practice Owner—

ADA Member—

Corporate Group—

Street Address—

Postal AddressSame as street address

Phone—

Email—

Assessment

Assessment Type—

Additional Practices—

Outreach Locations—

Authorisation

I am the Preferred Accreditation Contact and I am authorised to act for and on behalf of the nominated practice.

Terms and Conditions

I have read, and accept, the terms and conditions outlined in the 'QIP Private Dental Client Services Agreement'.

Confirmation

I verify the information provided in this form is true and correct. I declare that our practice meets the eligibility requirements to apply for accreditation.

Signature of Authorised Representative *

Use your mouse or finger to draw your signature above

First Name *

Authorised Representative

Last Name *

Authorised Representative

ADA Private
Dental Registration

QIP Private Dental Fees

Practice Details

Assessment

Additional Practice Sites

Outreach Sites

Authorisation

Terms and Conditions

Confirmation

ADA PrivateDental Registration

QIP Private Dental Fees

Practice Details

Assessment

Additional Practice Sites

Outreach Sites

Authorisation

Terms and Conditions

Confirmation

ADA Private
Dental Registration