ESTIMATE REQUEST
Office Name:
Primary Contact:
Address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
PERSONNEL INFORMATION
Number of Dentist:
Number of Hygentists:
Number of Aids:
Number of front office personnel:
(Include full-time, part-time and contracted personnel)
Is there an Automatic External Defibrillator (AED) in the office?
If yes, what make is it?
Is there an Emergency Medical kit in the office that includes emergency medications and airway supplies?
If yes, what make is it?
Are all office personnel currently certified in CPR and AED?
Please list your other general comments and questions: