By completing this survey, you give Pulpdent Corporation permission to use the information you provide below for quality assurance and compliance purposes.

1) How often do you personally apply fluoride varnish?

0-5 times per week

6-10 times per week

More than 10 times per week

*2) Which fluoride material do you use regularly?(Required.)

Embrace Varnish

Other (please specify)

*3) How long have you been using this material? (Required.)

0-1 year

1-3 years

More than 3 years

4) What do you like most about this product?

*5) Please rate the characteristics of the fluoride varnish you chose(Required.)

Excellent

Good

Fair

Poor

N/a

Color

Excellent

Good

Fair

Poor

N/a

Texture

Excellent

Good

Fair

Poor

N/a

Smell

Excellent

Good

Fair

Poor

N/a

Flowability

Excellent

Good

Fair

Poor

N/a

Handling

Excellent

Good

Fair

Poor

N/a

Cost

Excellent

Good

Fair

Poor

N/a

Ion Release

Excellent

Good

Fair

Poor

N/a

Patient Acceptance

Excellent

Good

Fair

Poor

N/a

6) For any answer of fair or poor, please explain:

*7) Have your patients experienced any negative issues such as allergic reaction, post-op sensitivity, or infection after use of this material?(Required.)

No

If yes, please specify

If yes, please rate the severity of the issue

Temporary mild

Temporary moderate

Temporary severe 

Required medical attention

Comments:

*Are you a dental healthcare provider?(Required.)

Yes

No

*I give Pulpdent consent to follow up in 6 months(Required.)

Agree

Disagree

We ask that you provide your contact information so we may reach you if needed to ensure the safety of our products. Information will not be used for marketing e-mails or phone calls, apart from notifying eligibility parties for gift card giveaways.

Name

Company

Email Address

Phone Number

Internal use only