Dental Questionnaire

3780 South 1550 West St. George, Utah 84790
Phone: (435) 627-4266 Fax (435) 634-5846
Dental Questionnaire
Application Date

Month Day Year
Date
Contact Information
Name of Business *
Contact Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email Address *
example@example.com
Amalgam Use
Number of patients per week
Number of fillings done on average per week
Type of fillings
Percentage of amalgam fillings
Number of amalgam fillings removed per week
Waste Management
Disposal method for amalgam
Contact amalgam
Non-contact amalgam
Are they disposed of together?

Yes No
Chair Information
Does the practice have chair side traps?

Yes No
If yes, how often are they cleaned?
How is the waste collected from the chair side traps disposed?

Recycled off-site Put in trash Put in biohazard bag Hazardous waste disposal Washed down sink
Vacuum Information
Are vacuum filters or some type of secondary filter used?

Yes No
If yes, how often are they cleaned?
How is the waste collected disposed?

Recycled off-site Put in trash Put in biohazard bag Hazardous waste disposal Washed down sink
Amalgam Separators
Does your practice use amalgam separators?

Yes No
If yes, what kind?
Is the Separator 2008 ISO 11143 standard compliant?

Yes No
How often is it serviced?
Does any other wastewater treatment exist to capture amalgam?

Yes No
If yes, please specify?
If waste amalgam is shipped to a refiner, please provide the name, address and phone number of the refiner.
Refiner Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
X-Ray Waste
How much x-ray fixer is disposed of per month?
What is the strength of the fixer?
Is fixer mixed with the developer?
How is the fixer disposed?

Recycled off-site Put in trash Put in biohazard bag Hazardous waste disposal Washed down sink after recovery Washed down sink without recovery
If a silver recovery unit is used please describe the procedures
If silver is taken off-site for disposal or recovery, please provide the name, address and phone number of the service provider.
Refiner Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
D. Certification
I hearby certify that the information found in this document is familiar to me, is complete and represents an accurate statement of fact to the best of my knowledge.
Name

First Name Last Name
Title
Date

Month Day Year
Date
Signature

Clear
Should be Empty:

Dental Questionnaire

Contact Information

Amalgam Use

Waste Management

X-Ray Waste

D. Certification