FORM -1

[See Rule - 4(a)]

APPLICATION FOR REGISTRATION OF TELANGNA ALLOPATHIC

PRIVATE DENTAL CARE ESTABLISHMENTS

(To be submitted in duplicate)

1. Name & address of the allopathic

Private Dental Care Establishment

2. Name of correspondent or any

Authorised person for correspondence

3. Name and address of the society / Trust

And date on which it was established
(Please enclose the relevant copies)

4. Whether the accommodation is owned

Establishment is on lease / rent. If so,
Please furnish the period of lease / rent
along with the documentary proof.
(Please enclose the relevant copies)

5. Date of establishment of Dental Care

establishment.

6. Total area of Establishment a) Open area

b) Constructed area
(One set of photographs of the premises
With its functional area to be furnished)

7. No. of Dental units

8. No. of Beds if any

9. Type of services offered a) General Dentistry

b) Specialty practice
c) Dental Laboratory services

10. Names of the Doctors / Dental Mechanic (DT)

Along with Registration Number allotted by
State Dental Councils
(Please enclose details)

11. Names of qualified Nursing Staff,

Registration numbers of NCI / Any other board
(Please enclose details)
 12. Names of staff, Para Medical /
Dental hygienist (DH)/ Dental mechanics (DT),
Their Registration numbers with
State Dental Council.
(Please enclose list of details)
13. No of supporting staff
(List to be enclosed)
14. No of Specialist available
(Please enclose the details)
15. The list of Equipment and furniture available
(Please enclose the details)

16. Operation theatres, if any

17. Whether Registration is sought

For main facility, of branches also,
If so details
(Separate application shall be submitted for each branch)
18. The financial position of the establishment
(Please enclose audit report of last two years)

19. Any other information relation to establishment

20. Declaration on Stamp paper for willingness

To comply with the prescribed rules is enclosed: YES / NO
21. Particulars of registration fee paid
(DD No., Name of the bank and date)

I here by declare that the information furnished above is true to the best of my knowledge and belief
and if it is found that any wrong information is furnished or suppressed the material facts, I will take full
responsibility for the consequential action as per law.

Signature

Name

Designation

Place

Date

Office Seal
 DOCUMENTS FOR REGISTRATION
1. Establishment photograph
2. Owner / director's photo
3. Xerox copy of State dental council registration of doctors
4. If own premises provide tax receipt or telephone bill
5. If leased - lease agreement.
6. Indian Dental Association membership
7. Any other Specialty association membership in case of specialist.
8. DD in favor of "District Reg.istration Authority (D.R.A.) & (DM&HO)"
9. Fees as per proforma,
1 O. No. of Doctors list with name, qualification & Registration No. allotted by State Dental Councils
Xerox copy of Certificates.
11. No. of Nurses, list with names, qualification & Registration; No. allotted by NCI / any other board
and Xerox copy of Certificates.
12. No. of Para Medical Staff, Dental Hygienist (D.H.), Dental Mechanics (D.T) list with name,
qualification &registration No. allotted by State Dental Council & Xerox copy of certificates. No. of
supporting staff list with names (receptionists, helpers Etc.)
13. No. of specialist available list with name, qualification & Registration No. allotted by State Dental
Council & Xerox copy of certificates
14. List of equipment and furniture.
15. Declaration on Non judicial stamp paper with notarized.
16. Previous (Two year) audit report.
17. All the documents and application form submitted in 1 + 1 with Spiral binding.
18. Phone No. of allopathic Dental care Establishment
19. Phone No. of correspondence allopathic Dental Care Establishment.
20. All Documents as per the order given above.
21. Copy of rates charges for each types of Services and same displayed at the reception counter in
both local and English and language.
22. Display of rates given in Appendix - III
FEE PARTICULARS:-

S.NO. DESCRIPTION OF ESTABLISHMENT ANNUAL REGISTRATION FEE

FEE FOR (5YEARS)
1. Clinics/ Consultation rooms (solo Practitioners) 250/- 1250/-
2. Poly Clinic (Group Practice) 500/- 2500/-
3. Dental Hospital with Inpatient facility (below 20 beds) 750/- 3750/-
4. Dental laboratory with basic facility (Acrylic work only) 500/- 2500/-
5. Dental laboratory with high end facility (labs catering
services other than mentioned in S.No 4) 2000/- 10000/-

DECLARATION PROFORMA

I here by declare that the information furnished above is true to the best of my knowledge and belief
and if it is found that any wrong information is furnished or suppressed the material facts, I will take full
responsibility for the consequential action as per law. The management of the establishment will abide and
follow the guide lines issued in G.O.Ms No 135 HM & FW K2 dt.28.04.2007. and instruction issued thereon by the
govt. from time to time in this matter.

Notarized Signature of the owner and seal

 SI. NAME OF THE CLINICAL PROCEDURE CHARGES
1.
No. Consultation
2. IOPA
3. Extraction
4. Impaction-Mesio Angular and Disto Angular
5. Abscess Incision
6. Alveoloplasty (Quadrant)
7. Fracture Reduction closed
8. Splinting
9. Apicectomy in L.A.
10. Apicectomy with Grafting
11. Operculectomy
12. Composite Veneering L.C. Per Tooth
13. Removable appliances
14. Fixed Beggs Appliances
15. Fixed Straight Wire Appliance
16. Activator
17. Habit breaking appliance Fixed
18. Habit breaking appliance Removable
19. Zinc Oxide - Eugenol Filling
20. Amalgam Class I and Class 11
21. GIC Class I, Class 11 and Class V
22. Light Cure Restoration
23. Metal Ceramic Crown
24. Full Ceramic Crown
25. Anterior Root Canal Treatment
26, Posterior root canal treatment
27. Nickel Chrome Crown
28. Post and Core
29. Oral Prophylaxis
30. Flap Surgery (per quadrant)
31. Gingivectomy (Per Quadrant)
32. Removable Partial Denture with Single Tooth
33. Each Additional Tooth
34. Complete Denture Set
35. Repair of Denture
f Make the Charges list as per the services provided in your establishment.
S.No NAME OFTHELABORATORY PROCEDURE CHARGES
1. Acrylic partial denture Single tooth (Self cure resin)
2. Additional tooth

I 3.
4.
5.
Acrylic partial denture Single tooth (Heat cure resin)
Additional tooth
Heat cure Complete denture (Upper)
6. Heat cure Complete Denture (Lower)
7. Halies Plate
8. Orthodontic appliance with expansion screw
9. Night guard
10. Bleaching tray
11. Habit breaking appliance
12. Activator
13. Francle's appliance
14. Metal crown
15. Metal crown with Acrylic facing (Per unit)
16. Metal crown with composite facing (Per unit)
17. Metal crown with ceramic facing (Per unit)
18. Metal ceramic crown (Per unit)
19. Metal free ceramic crown (Per unit)
20. Metal free CAD CAM crown (Per unit)
I 21. Cast partial denture frame work
I 22. Partial denture with precession attachments
Make the rate list as per the services provided in your establishment.
,