Registration No.

(Medical institution code)

Legal representative

(Seal)

(Primary person in charge)

Date of application

MM DD, YYYY

Name

Address

Legal representative

(Primary person in charge)

Ownership form

Service recipient

Service mode

Registered capital

Total:

Total:

Fixed capital:

Fixed capital:

Current capital:

Current capital:

Diagnosis and treatment items

Sickbeds (dental chairs)

Remarks

Reasons for modification registration application

Legal representative

(Primary person in charge) Signature:            MM DD, YYYY

Address of the medical institution:

Postal code:              Contact:                 Tel.:

Opinions signed by the superior competent authorities

MM DD, YYYY (Official seal)

Review (investigation, verification) personnel opinion

Signature:                      MM DD, YYYY

Approval of Modification Registration Items

Name

Address

Legal representative (primary person in charge)

Ownership form

Service recipient

Service mode

Registered capital

Diagnosis and treatment items

Sickbeds (dental chairs)

Remarks:

Opinion of the main reviewer

Signature:                      MM DD, YYYY

Opinion of the supervisor

Signature:                      MM DD, YYYY

Approval of the commission director

Signature:                      MM DD, YYYY

Date of approval

Signature of the recipient

Date of receipt

Contact address

Tel.

Signature of the issuer

Date of issuance

Archiving of registration documents, certificates and materials

Signature of archive management personnel:      MM DD, YYYY

Record of the publication of registration announcements of the medical institution

Signature of the recorder:                 MM DD, YYYY

Remarks