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香港大學牙醫學院
+852 3979 9191
香港皇后大道西460號翰林峰2樓
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Clinical Privileges Application Form
English Full Name
Title (Please refer to the Clinical Privilege Table)(e.g. Honorary Dental Officer)
Contact Number
Email
Copy of Student Enrolment / Appointment record at Faculty of Dentistry
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Copy of Licensure
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Copy of Dentist Registration
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Copy of Liability Insurance (MPS)
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For Faculty Staff, please submit your Clinical Outside Practice Eligibility Letter
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Image of other relevant documents
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Pdf of other relevant documents
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Other remarks for your application
I, the applicant, hereby declare and certify that the documents uploaded for this application are true and accurate copies of the original documents. I understand that I will bear full responsibility and liability for any false or fraudulent documents submitted.
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