Practice details

ABN*

Trading Name*

Group Name

If you require the accreditation for more than one dental practice in a group, please enter group name above. All practices in a group must hold the same ABN.

Practice Physical Address

Floor number & Building

Street number and street name*

Suburb*

State*

Post code*

Postal address

Same as physical address

Floor number & Building

Street number and street name

Suburb

State

Post code

Preferred accreditation contact

Contact Name*

Contact Position*

Phone*

Email*

Proprietor's Name*

Proprietor's Email Address

Australian Dental Association (ADA) Membership
Yes

Other practices*
This is the only practice participating in the accreditation scheme I am responsible forI am responsible for other dental practices seeking accreditation

Sites

Total number of sites for accreditation (must be under the same ABN)*

Verify authenticity

Please review the information you have entered for accuracy, ensuring that at minimum all the compulsory fields are completed. Giving false or misleading information is a serious offence. Full terms and conditions are available on this website.

Name of person completing form

I confirm I have permission to act on behalf of the Dental Practice named above, and that I am able to authorise this enrolment with HDAA Australia Pty Ltd for accreditation to the “National Safety and Quality Primary and Community Healthcare Standards” and to verify the completeness and accuracy of the information provided in this enrolment and associated application documentation (when submitted for assessment). I understand and accept on behalf of the Dental Practice named above the conditions of accreditation. I agree that fees will be paid within fourteen (14) days of receipt of invoice.

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