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:
Please provide the make and model of your Ultrasonic Machines and Instrument Washers:
Please provide pictures/ close-ups of your Sterilizers and Ultarsonic Machines (one picture each) (unlimited qty);
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Take Photo (limit of 1 photo)
Please provide the name/type of disinfectants for the following uses;
Low Level
High Level / Cold Soak
Enzymatic
Evacuation Cleaner
Additional (i.e. cleaning agents used for floors,etc.)
*
Please provide the make, model and location of the eyewash station on site;
*
What type of packaging do you use in your sterilizers?
*
Pouches
Cassettes
Both
What type of dental radiography is used?
*
Film
Digital
Both
Do you currently have a specific procedure for the following (click all that apply); if not, a generic policy will be included in your manual.
Soaking Tub
Manual Cleaning Process
Instruments Drying
Process for Labelling Packages
Blood/Body Fill Spill Clean-up
Removal of Faulty Dental Devices/Equipment
Morning Cleaning of Operatory
Between Patient Cleaning of Operatory
End of Day Cleaning of Operatory
Improperly Reprocessed Equipment
Boil Water Advisory
Cleaning of Linens
Please describe the process (including type of solution used) for soaking:
*
Option: To include a photo for your Soaking procedure (unlimited photos)
Take Photo (limit of 1 photo)
Please describe the Manual Cleaning Process (disposable vs. non-disposable brushes;
*
Option: To include a photo of your procedure for Manual Cleaning (unlimited photos)
Take Photo (limit of 1 photo)
Please describe the Instrument Drying process;
*
Option: To include a photo of your procedure for Instrument Drying (unlimited photos)
Take Photo (limit of 1 photo)
Please describe the procedure for Labelling Packages;
*
Option: To include a photo of your procedure for Labelling Packages; (unlimited photos)
Take Photo (limit of 1 photo)
Please describe your procedure for Blood/Body Fluid Spill Clean-up;
*
Option: To include a photo of your procedure for Blood/Body Fluid Spill Clean-up; (unlimited photos)
Take Photo (limit of 1 photo)
Please describe your procedure for Removal of Faulty Dental Devices/Equipment;
*
Option: To include a photo of your procedure Removal of Faulty Dental Devices/Equipment; (unlimited photos)
Take Photo (limit of 1 photo)
Please describe your procedure for Morning Cleaning of the Operatory;
*
Option: To include a photo of your procedure for Morning Cleaning of the Operatory (unlimited photos)
Take Photo (limit of 1 photo)
Please describe your procedure for Between Patient Cleaning of the Operatory;
*
Option: To include a photo of your procedure for Between Patient Cleaning of the Operatory (unlimited photos)
Take Photo (limit of 1 photo)
Please describe your procedure for End-of-Day Cleaning of the Operatory;
*
Option: To include a photo of your procedure for End-of-Day Cleaning of the Operatory (unlimited photos)
Take Photo (limit of 1 photo)
Please describe your procedure for Improperly Reprocessed Equipment;
*
Option: To include a photo of your procedure for Improperly Reprocessed Equipment (unlimited photos)
Take photo (limit of 1 photo)
Please describe your procedure/system used during a Boil Water Advisory;
*
Optional: To include a photo of your Boil Water Advisory Procedure (unlimited photos)
Take Photo (limit of 1 photo)
Please describe your procedure for Cleaning of Linens;
*
Optional: To include a picture of your Cleaning Linens procedure (unlimited photos)
Take Photo (limit of 1 photo)
Submit
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