Fluoride Varnish

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

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* 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

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* 2) Which fluoride material do you use regularly?

Embrace Varnish

Other (please specify)

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

0-1 year

1-3 years

More than 3 years

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* 4) What do you like most about this product?

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

	Excellent	Good	Fair	Poor	N/a
Color	Color Excellent	Color Good	Color Fair	Color Poor	Color N/a
Texture	Texture Excellent	Texture Good	Texture Fair	Texture Poor	Texture N/a
Smell	Smell Excellent	Smell Good	Smell Fair	Smell Poor	Smell N/a
Flowability	Flowability Excellent	Flowability Good	Flowability Fair	Flowability Poor	Flowability N/a
Handling	Handling Excellent	Handling Good	Handling Fair	Handling Poor	Handling N/a
Cost	Cost Excellent	Cost Good	Cost Fair	Cost Poor	Cost N/a
Ion Release	Ion Release Excellent	Ion Release Good	Ion Release Fair	Ion Release Poor	Ion Release N/a
Patient Acceptance	Patient Acceptance Excellent	Patient Acceptance Good	Patient Acceptance Fair	Patient Acceptance Poor	Patient Acceptance N/a

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

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

If yes, please specify

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* If yes, please rate the severity of the issue

Temporary mild

Temporary moderate

Temporary severe

Required medical attention

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* Comments:

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* Are you a dental healthcare provider?

Yes

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* I give Pulpdent consent to follow up in 6 months

Agree

Disagree

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* 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

Fluoride Varnish

Question Title

* 1) How often do you personally apply fluoride varnish?

Question Title

* 2) Which fluoride material do you use regularly?

Question Title

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

Question Title

* 4) What do you like most about this product?

Question Title

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

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

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

Question Title

* If yes, please rate the severity of the issue

Question Title

* Comments:

Question Title

* Are you a dental healthcare provider?

Question Title

* I give Pulpdent consent to follow up in 6 months

Question Title

* 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.

Question Title

* Internal use only