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Post Dental Training
Follow-up Survey
Return to CHDP Home page
Date of Training:
+
I am a:
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Physician
NP
RN
PA
MA
Other Staff:
Other Staff:
1. Does your clinic currently offer fluoride varnish treatment to patients as a preventive measure to dental disease?
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We provide fluoride varnish treatment to all children ages 0-6.
We provide fluoride varnish treatments to all children ages 0-12.
We provide fluoride varnish treatments to all children ages 0-18.
We do not currently offer fluoride varnish treatments to our patients.
2. Does your clinic have a posted fluoride varnish protocol/standing order?
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Yes
No
3. Have you been trained on your clinic’s fluoride varnish protocol/standing order?
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Yes
No
N/A
4. If your clinic is
NOT
currently offering fluoride varnish treatment to patients, what are the barriers to implementing fluoride varnish protocol?
Additional comments:
Attendee name:
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Clinic/Office:
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Address:
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City:
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Zip Code:
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Email:
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Phone number:
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