Welcome Discover how a well-designed, supported water testing program makes dental water compliance simple and reliable.Please complete the dental waterline profile and assessment below to ensure a thorough scoping of your practice’s configuration. Clinic Information Clinic Name * Internal Clinic Name The internal or alternate name used to identify a dental practice within your organization. Clinic Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Number of Operatories * Do your chairs have rear delivery? * Yes No Water Source What’s the quality of your municipal tap water measured in parts per million (PPM) total dissolved solids (TDS)? * Not sure about the TDS content in your water tap water? Don’t worry, we’ll get an accurate measurement when we test your water. <100ppm 101-250ppm 250+ppm Don't Know Is there any form of water filtration or softener used at your facility? * Select all that apply Centralized Filtration Water Softner Not Sure None How is water supplied to your chairs? * Independent Bottle Reservoir Direct Feed Hybrid What grade of water are you using in your chairs? * Municipal Tap Water (from a faucet) Purified Water (made in office) Purified water (delivery service or store bought) Distilled water (from a distiller) Shock Treatments Are shock treatments part of your current protocol? * Yes No Shock treatment method used: * Citrisil Shock ICX Renew Liquid Ultra Bleach VistaTab **Not Applicable** How often are shock treatments performed? * Intermittent Cycle (Monthly, Quarterly, Semi-annually, Annually) As Needed (Protocol Breaches, water test failures, etc) *Not Applicable** Maintenance Treatments Are maintenance treatments part of your current protocol? * Yes No When did you start employing maintenance treatments? * In the last 2 years More than 2 years ago **Not Applicable* What maintenance treatments are used? Tablets (Citrisil, BluTab, ICX, etc) Straws (Sterisil Straw, BluTube, etc) Cartridges (Sterisil Cartridge, Dental Pure Cartridge, etc) Systems (Sterisil System G4, VistaClear DP, etc) Micro Filtration **Not Applicable** How do you keep track of replacing or repurchasing maintenance products? * Paper Log Web Portal Dealer Rep Reminder Digital Reminder **Not Applicable** Thank you for participating in the Agenics Pilot Study program. We will review your responses and get back to you to setup your water test and consultation. The endYou made it! Be sure you’ve answered all the questions and click the “Submit” button.Rest assured, you’re in good hands.
