The air compressor and dental vacuum are often referred to as the heart and lungs of a dental practice. When a catastrophic failure occurs, practice revenue is at RISK. 

The assessment will identify the following:

- The age and model of the vacuum and air compressor
- Suction line cleaning protocols
- Annual maintenance/compliance
- Overall condition of the utility room 

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1. Office Information (Required.)

Office Protocols

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2. How often do you clean the suction lines? (Required.)

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3. Method to clean vacuum lines? (Required.)

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4. What product do you use to clean the vacuum lines? (Required.)

Vacuum Information

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5. Model: (Required.)

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6. Manufacture date: (Required.)

Date

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7. Serial Number: (Required.)

Compressor Information

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8. Model:

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9. Manufacture date: (Required.)

Date

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10. Serial Number:

Amalgam Separator Information

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11. Model: (Required.)

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12. Manufacture date: (Required.)

Date

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13. Serial Number: (Required.)

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14. Does the office perform annual maintenance on the air compressor? (Required.)

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15. Please upload a photo of the room: Vacuum Image 

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16. Please upload a photo of the room: Compressor Image 

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17. Please upload a photo of the room: Amalgam Separator Image 

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18. Please upload a photo of the room: Misc

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19. Provide any additional feedback:

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