Exit this survey

Quality Feedback Card

Please fill in the form below

Question Title

* 1. TTC Reference number

Question Title

* 2. Dentist name

Question Title

* 3. Date Fitted

On what date was this restoration fitted?

Date

Question Title

* 4. Cement Used

Question Title

* 5. Which lab did the restoration?

Other (please specify)

Question Title

* 6. What type of restoration was this?

Question Title

* 7. What was the quality of the crown like?

	Excellent	Good	Average	Poor
Marginal Fit	Marginal Fit Excellent	Marginal Fit Good	Marginal Fit Average	Marginal Fit Poor
Anatomic Form	Anatomic Form Excellent	Anatomic Form Good	Anatomic Form Average	Anatomic Form Poor
Overall Aesthetics	Overall Aesthetics Excellent	Overall Aesthetics Good	Overall Aesthetics Average	Overall Aesthetics Poor

Question Title

* 8. Was there any adjustment required on this restoration by yourself?

	None	Minor	Significant	Cooling	Polish
Occlusal	Occlusal None	Occlusal Minor	Occlusal Significant	Occlusal Cooling	Occlusal Polish
Marginal	Marginal None	Marginal Minor	Marginal Significant	Marginal Cooling	Marginal Polish
Contact	Contact None	Contact Minor	Contact Significant	Contact Cooling	Contact Polish
Fit Surface	Fit Surface None	Fit Surface Minor	Fit Surface Significant	Fit Surface Cooling	Fit Surface Polish