MPDPA Covid 19 Vaccine Registration Form.
As directed by the Ministry Of Health, this is a Registration Form for our Members in Benefit in line with the Government’s effort to vaccinate the front-liners including the Dental Private Practitioners and their Staffs.
We are also aware you may have filled in similar forms before by MMA (Malaysian Medical Association ) and MDA ( Malaysian Dental Association).

MPDPA is merely doing our part to ensure Our Members In Benefit are Not Left Out!
If you have more than one dentist  in your practice, kindly ensure to fill in a separate form.
1 dentist = 1 form.
 
Kindly fill in this form & Submit by Saturday, 20th Feb 2021.


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MALAYSIAN PRIVATE DENTAL PRACTITIONERS' ASSOCIATION
NAME OF DENTIST / DENTIST IN CHARGE : *
NRIC No : in this format : 001234 56 7890 *
CONTACT NO :  ( please ensure your number is in service! ) *
HOW TO CHECK FOR YOUR My SEJAHTERA ID :
My Sejahtera ID : *
EMAIL ADDRESS  : *
CLINIC ADDRESS  ( in FULL ) : *
NO OF STAFF :
Name of Staff , NRIC No , Contact No, My Sejahtera ID ( Eg: Jane Doe, 123456 78 9123, 0112345678, 60112345678 )
Name of Staff , NRIC No , Contact No, My Sejahtera ID (  Eg: Jane Doe, 123456 78 9123, 0112345678, 60112345678 )
Name of Staff , NRIC No , Contact No, My Sejahtera ID (  Eg: Jane Doe, 123456 78 9123, 0112345678, 60112345678 )
Name of Staff , NRIC No , Contact No, My Sejahtera ID (  Eg: Jane Doe, 123456 78 9123, 0112345678, 60112345678 )
Name of Staff , NRIC No , Contact No, My Sejahtera ID (  Eg: Jane Doe, 123456 78 9123, 0112345678, 60112345678 )
Name of Staff , NRIC No , Contact No, My Sejahtera ID (  Eg: Jane Doe, 123456 78 9123, 0112345678, 60112345678 )
Name of Staff , NRIC No , Contact No, My Sejahtera ID (  Eg: Jane Doe, 123456 78 9123, 0112345678, 60112345678 )
Name of Staff , NRIC No , Contact No, My Sejahtera ID (  Eg: Jane Doe, 123456 78 9123, 0112345678, 60112345678 )
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