Program Vaksin Selangor: Private Clinic Registration

Program Vaksin Selangor Private Clinic Registration Form

Name

SSM No

Doctor In Charge

APC No (Dr.)

APC Expiry Date

Address Information

Address1

Address2

Postcode

City

State

Contact Information

Phone

Fax

Staff In Charge

APC No (Staff)

APC Expiry Date

Designation

Identification No

Bank Account Information

Bank

Account No

Payee Name

Panelship Eligibility Requirements

Have proper cold chain equipment. Min: Cold box, electronic data logger & pharmaceutical fridge (2-8°C)

Have adequate number of appropriately trained medical & non-medical staff. Min: 1 doctor, 1 nurse, 1 MA, 1 volunteer*

Have adequate space for patients to wait and be observed post-vaccination for a minimum of 15-30 mins while adhering to physical distancing requirements

Prepare appropriate emergency equipment to manage emergency cases related to Covid-19

Maybe required to collect vaccination from the nearest SelCare Clinic / Panel clinic

I have a copy of Certificate of registration to operate private medical clinic (Borang B or Borang F)

I have a copy of current annual practising certificate (APC) of person-in-charge

Acknowledgement and Acceptance of Terms and Conditions is required

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