Dental Questionnaire

2176 W. Treatment Plant Rd., St. George, Utah 84790
Phone: (435) 627-4266 Fax (435) 634-5846
Dental Questionnaire
Application Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Information
Name of Business
Contact Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone 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?
Chair Information
Does the practice have chair side traps?
If yes, how often are they cleaned?
How is the waste collected from the chair side traps disposed?

Other
Vacuum Information
Are vacuum filters or some type of secondary filter used?
If yes, how often are they cleaned?
How is the waste collected disposed?

Other
Amalgam Separators
Does your practice use amalgam separators?
If yes, what kind?
Is the Separator 2008 ISO 11143 standard compliant?
How often is it serviced?
Does any other wastewater treatment exist to capture amalgam?
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

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone 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?

Other
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

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone 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 NameLast Name
Title
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Dental Questionnaire

Contact Information

Amalgam Use

Waste Management

X-Ray Waste

D. Certification