Dental Questionnaire

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

MonthDayYear
Date
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?

YesNo
Chair Information
Does the practice have chair side traps?

YesNo
If yes, how often are they cleaned?
How is the waste collected from the chair side traps disposed?

Recycled off-sitePut in trashPut in biohazard bagHazardous waste disposalWashed down sinkOther
Vacuum Information
Are vacuum filters or some type of secondary filter used?

YesNo
If yes, how often are they cleaned?
How is the waste collected disposed?

Recycled off-sitePut in trashPut in biohazard bagHazardous waste disposalWashed down sinkOther
Amalgam Separators
Does your practice use amalgam separators?

YesNo
If yes, what kind?
Is the Separator 2008 ISO 11143 standard compliant?

YesNo
How often is it serviced?
Does any other wastewater treatment exist to capture amalgam?

YesNo
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?

Recycled off-sitePut in trashPut in biohazard bagHazardous waste disposalWashed down sink after recoveryWashed down sink without recoveryOther
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
Date
Signature

Clear
Should be Empty:

Dental Questionnaire

Contact Information

Amalgam Use

Waste Management

X-Ray Waste

D. Certification