36C24418Q0306-009.docx

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Pittsburgh Dental Prostheses Lab RFQ - FBO
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36C24418Q0306
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36C24418Q0306 Attachment 3 - Evaluation Form.docx

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Attachment3

VA PITTSBURGH HEALTHCARE SYSTEM DENTAL SERVICE

DENTAL LABORATORY EVALUATION FORM

Date _____________________ Dental Lab Name _________________________ Dentist _______________________________ Patient Name __________________________ Prosthesis _____________________________________________________________ Part 1 – Clinical Competency

Outstanding

Clinically Acceptable

Not Clinically Acceptable (requiring Significant alteration or remake)

RX followed as written

Overall Quality of Prosthesis/or item ordered

Occlusion (if applicable)

Neatness (including finish, polish if applicable)

Part II - Logistics

Yes

No

Damage to casts of mounting a prosthesis

Damage to instrumentation

Delivered in a timely manner

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