DENTAL CAMP REQUEST FORM 

Thank you!  for your interest in our oral health outreach services.

Kindly fill out this Google form (will take less than 5 minutes) and submit it to us at least 5 weeks before the proposed date. 

This is because we need to get the required approvals from the Malaysian Dental Council and be part of the Outreach program.

For any query or information please mail us -   dph@pidc.edu.my

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ORGANIZATION INFORMATION

1.      Name of the Organization requesting Dental Camp:

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2.      Contact Person:

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3.      Contact Email:

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4.      Contact Phone:

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EVENT DETAILS

1.      Event Name:

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2.      Event Date:

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DD
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3.      Event Time:

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Time
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4.      Event Location:

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5.      Target Audience:

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6.      Age Group:

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7.      No. of Participants(expecting):

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8.       Objectives of the Outreach:

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SERVICES REQUESTED

Services Requested

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