Mobile Dental Practice Checklist Form
Complete this operational checklist before beginning mobile dental services to ensure readiness and safety. All fields are required for a thorough pre-visit assessment.
Date of Checklist
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Member Name
*
First Name
Last Name
Mobile Dental Vehicle/Unit Ready for Operation
*
Yes
No
All Dental Equipment Set Up and Functioning
*
Yes
No
Supply Inventory Checked and Sufficient
*
Yes
No
Sterilization and Disinfection Completed
*
Yes
No
Patient Area Set Up and Clean
*
Yes
No
Power and Water Supply Checked
*
Yes
No
Personal Protective Equipment (PPE) Available
*
Yes
No
Emergency Kit Present and Accessible
*
Yes
No
Submit Checklist
Should be Empty: