Office Design Questionnaire

Every doctor has his or her own method of working and organizing. The questionnaire is designed to communicate all pertinent information that will help us design an office to fit your goals and requirements. It also assists us in organizing and arranging priorities for the new office. The more you can input specific needs and concerns, the better your finished office will be.

Planning Sheet

Download and print the Planning Sheet PDF Document* and draw a scaled floor plan of your office. Show the locations of windows, doors, electric service (fuse panel), existing bathrooms and physical items that cannot be moved. Remember to indicate field measurements to verify the physical sizes at all locations. Fax your completed planning sheet to 972-775-8758. Complete and submit the form below.

Doctor's Contact Information

Doctors' Names
Office Phone
Home Phone
Fax Number
E-Mail Address

General Information

Square Footage
Number of Doctors		Right-Handed Left-Handed
Type of Delivery System Required		Left Side Over Patient Rear Right Side Other
Number of Office Personnel		Orthodontists Secretary Receptionist Full-Time Chair Assistants Part-Time Chair Assistants Lab Techs Sterilizing Other
Number of Chairs Required		In Bay Area In Adult Area In Bonding Area In Consultation Area In Exam Area In Records Room Other
Number of Chairs Presently
Chair Manufacturer(s)
Number of Units Presently
Unit Manufacturer(s)

Equipment Information

Operatory Lighting		ELEF Unit Mounted Gooseneck Ceiling Alger Other
Sterilization		Area   Room   Not Applicable Sterilizer Dentronix DDS 5000 Other
Computers		Number
		Locations

Room Sizes

Waiting Room (Number of Chairs)
Kids Area		S      M      L      XL
Reception Area		S      M      L      XL
Business Office		S      M      L      XL
Storage Room		S      M      L      XL
Tooth Brushing Area (Number of sinks)
On Deck Area (Seating Capacity)

Office Layout

Consultation Room		Size Table Chairs Exam Chair Viewbox Sink Other
Records Room		Pan Ceph Pan-Ceph Wehmer Type Exam Chair Bubbler Unit to Double as Adult Room Photo Wall Other
Digital X-Ray System (No Dark Room Needed)		Digident CR System Other Type
Dark Room		Manual Tank Automatic Processor Sink
Laboratory		Number of Sinks Wet Lab Dry Lab Model Trimmer Wehmer Dual Wheel
Patient Bathroom		In Suite Outside Number of Handicap Required

Other Rooms

Staff Lounge		Sink Cabinets Refrigerator Bathroom
Patient Education		Room   Alcove   Not Applicable Sink Cabinets Mirror Other
Doctor's Private Office		Desk Size Number of Chairs Bathroom Shower Other
Mechanical Room		Inside Suite Outside Suite
Equipment Location (in or out of suite, location in suite)		Heating-Air Water Heater Compressor Vacuum Pump Washer/Dryer Nitrogen

Miscellaneous

Private Entrance		Doctor Staff
Entrance Each Day		Front Door Rear Door
Exit Each Day		Front Door Rear Door
Other

Security Code

Security Code			Refresh
Enter Security Code

 

If you prefer a paper form, please download and print the entire Facility Design Questionnaire PDF document and fax the completed form to 972-775-8758.

  * You must have Adobe Reader installed to view PDF documents.

Orthodontic Office Design

• Office Design Service
• Sterilization Centers
• How To Get Started
• Design Questionnaire

Instrument Delivery Units

• Saturn Model H  
• Saturn Model C
• Saturn LSU Model 2000
• Saturn System Model 1191
• Ross Model A
• Protegé
• The Phoenix  
• Spacemaker
• Spacemaker Plus
  
• Saturn II Mobile
• Mini Pro Mobile
• Self-Contained Unit
  

Chairs & Stools

• Maxus Chair
• Optima Chair
• Optima Chair with Power Base
• Flexion Stool
• Flexion Assistant's Stool
• Simplicity Stool

Lighting

• ELEF-Electronic Light Ejection Fixtures
• Goose Neck Task Light
• Curved Post Task Light

Mechanical

• Model Trimmer 108P
• Vacuum Mixer
• Dry Air Compressor
• Compact Compressor
• Vacuum Pumps
• Thermal Electric Ligature Director

Equipment Color Charts