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

Office Protocols

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* 2. How often do you clean the suction lines?

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* 3. Method to clean vacuum lines?

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* 4. What product do you use to clean the vacuum lines?

Vacuum Information

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* 5. Model:

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* 6. Manufacture date:

Date

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* 7. Serial Number:

Compressor Information

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* 8. Model:

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* 9. Manufacture date:

Date

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* 10. Serial Number:

Amalgam Separator Information

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* 11. Model:

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* 12. Manufacture date:

Date

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* 13. Serial Number:

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* 14. Does the office perform annual maintenance on the air compressor?

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

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 16. Please upload a photo of the room: Compressor Image 

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 17. Please upload a photo of the room: Amalgam Separator Image 

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 18. Please upload a photo of the room: Misc

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 19. Provide any additional feedback:

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