Kingdom of Saudi Arabia

‫المملكة العربية السعودية‬

MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

DENTAL
NAME: EMPLOYEE NUMBER:
ID NUMBER: YEARS OF
EXPERIENCE:
SAUDI COUNCIL REGISTRATION #: DATE OF EXPIRATION:

Designation:

 RESIDENT  SPECIALIST  CONSULTANT

Certification/s:
 BCLS  ACLS  ATLS  PALS  Other/s (please specify)________________

Clinical Privilege Category:

 TEMPORARY  APPROVED  EMERGENCY
At the time of a life-threatening clinical emergency, any Practitioner may render whatever care he/she believes to
be indicated regardless of the extent of his/her granted privileges.
Instructions:
APPLICANT: In the first column below, place a check in the appropriate box whether you have requested for the
privileges listed on the second column.
GENERAL INSTRUCTION: Please tick () in the appropriate column whether the privileges that the applicant
applied for is “GRANTED”, “GRANTED WITH SUPERVISION” or “DENIED”. (If the requested privileges
are either “GRANTED WITH SUPERVISION” or “DENIED”, the “REMARKS” column may be necessary to be
filled up).
Note: A copy of this privilege list will be given to the applicant. The original privilege list will be kept in the
“Personnel File”. The Clinical Privilege of Medical Staffs will be reviewed every 2 years along with their Annual
Evaluation for Contract Renewal or as necessary. (For New Medical Staffs, review of privilege will be after 90
days from the start of employment.)

REQUESTED GRANTED
CLINICAL
GRANTED WITH DENIED REMARKS
YES NO PROCEDURES
SUPERVISION
GENERAL (BASIC) PROCEDURES
  Admitting Privileges   
Conscious IV Sedation
    
(May require Anesthesia

MS-001 (2) Page 1 of 4

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

DENTAL
approval)
DENTAL SURGERY
General dental procedures requiring skills usually acquired upon graduation from an accredited Dental
School and a General Practice Residency
  Oral Sedation   
Direct/Indirect Pulp
 
capping
ENDODONTICS
Direct/Indirect Pulp
    
capping
  RCT Single Canal   
  Endodontic Treatment   
ORAL AND MAXILLOFACIAL SURGERY
Non surgical dental
    
extraction
  Frenectomy   

REQUESTED GRANTED
CLINICAL
GRANTED WITH DENIED REMARKS
YES NO PROCEDURES
SUPERVISION
ORAL AND MAXILLOFACIAL SURGERY - CONTINUATION
Removal of impacted
    
tooth tissue
Surgical removal of
    
roots
Removal of impacted
    
tooth, completely bony
Removal of impacted
tooth, completely bony
    
with unusual
complications
PEDODONTICS
  Posterior restorations   

MS-001 (2) Page 2 of 4

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

DENTAL

  Anterior restorations   
Pulp therapy of
    
deciduous teeth
  Tooth extractions   
  Surgical extractions   
RESTORATIVE
  Occlusal adjustment   
Anterior composite
    
restoration
Anterior composite build
    
up
Posterior composite
    
restoration
Posterior composite
    
build up
  Composite splint   
Glass Ionamer
    
restoration
  Compomer restoration   
  Amalgam restoration   
  Amalgam build up   
  Inlay and Onlay   
BLOOD TRANSFUSION AND INFUSION
Infusion (IV Fluids,
    
plasma, etc.)
  Intravenous medicines   
Blood transfusion- whole,
    
packed cells

If at any stage you wish to perform any surgical or therapeutic procedure that is not listed in this application, you
must refer to the Credentialing and Privileging Committee.

CLINICAL PRIVILEGES APPROVAL

NAME & DESIGNATION STAMP & DATE

MS-001 (2) Page 3 of 4

Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
MINISTRY OF HEALTH General
‫وزارة الصحة‬
Directorate For Health Affairs Of Najran
‫المديرية العامة للشئون الصحية بمنطقة نجران‬
Region
‫مستشفى بدر الجنوب العام‬
Bader al-Janoub General Hospital

APPLICATION FOR CLINICAL PRIVILEGES IN

DENTAL
SIGNATURE

Requested by:
___________________________

Recommended by: Dr. Abdulkharim

Head of Dental Department

Dr. Anwer Nehal Ghouri

Medical Director/
Medical Credentialing & Privileging Committee
Chairman
Approved by:

Mr. Ibrahim Hamad Mana Al Amer

Hospital Director

MS-001 (2) Page 4 of 4