Dental Custom Policy Manual Order Form
Name Of The Practice/ Location
*
Name Of The Practice
Location
Name of Individual Completing Order Form
*
First & Last Name
Title
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Do you want your company logo to be included in the manual?
*
Yes
No
Company Logo
Please provide the make and model of your sterilizers, ultrasonic washers, automated instrument washers, handpiece lubricators, and eyewash station
Please provide photos of each of your sterilizers, ultrasonic washers, automated instrument washers, handpiece lubricators, and eyewash station
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What testing do you perform in your sterilization centre?
Ultrasonic
Automated Washer
Biological Indicator
Bowie-Dick Testing
Please provide pictures of the ultrasonic, automated washer, and biological indicator testing performed.
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What type of sterilization documentation do you use?
Paper
Digital
Combination
Note:
Do you use a Process Challenge Device (PCD)?
Yes, Homemade
Yes, Commercially Made
No
Photo Upload
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Please provide the names for each of the following products as applicable
Low-level Disinfectant
High-level Disinfectant/Cold Soak
Enzymatic
Evacuation Cleaner
Waterline Testing Kit
Local public health unit
What type of packaging is used in your sterilizers?
Pouches
Cassettes
What type of radiography is used?
Film
Digital
Plates
Is an external linens service contracted for gowns, towels, blankets, or other laundry supplies?
Yes
No
If yes, which linen company do you use, and how often is it picked up?
Please provide a picture of the containers used to transport contaminated instruments
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Where are sharps containers available at the practice?
Are biopsy specimens collected at this practice?
Yes
No
Where are your eyewash stations located?
Submit
Should be Empty: