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Evaluation of the clinical effectiveness and safety of the GLAZE medical device

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Evaluation of the clinical effectiveness and safety of the GLAZE medical device

Doctor's personal details, professional licence number

Please provide your first name, surname and professional licence number. Please be aware that your personal data will not be collected, processed or disseminated without your knowledge and consent. It will only be used to confirm that the survey has been completed by an authorised person.

Please be informed that your data obtained as a result of previous contacts with ARKONA Laboratorium Farmakologii Stomatologicznej Grzegorz Kalbarczyk (hereinafter referred to as ARKONA) is stored in the ARKONA Contractor Database, which is the administrator of your personal data. Details regarding ARKONA's personal data protection policy are available at https://arkonadent.com/wp-content/uploads/2020/10/arkonadent.com-polityka-prywatnosci.pdf. If you would like to obtain detailed information about the rules and purposes of ARKONA's processing of your personal data, please contact us at the following e-mail address: polityka.prywatnosci@arkonadent.com or at the postal address Nasutów 99C, 21-025 Niemce, Poland.

Address of the dental clinic/ practice

Email address of the doctor or clinic

Medical Representative's initials

If applicable
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Evaluation of the clinical effectiveness and safety of the GLAZE medical device

Since when have you been using the GLAZE medical device?

Select one answer

How often do you use GLAZE in your practice?

Select one answer

How would you assess the volume (3 ml) of material in the GLAZE package?

Select one answer

For which clinical indications do you use the GLAZE?

You can select any number of options.

Have you ever used the GLAZE medical device on:

Select one answer in each line

How would you assess the clinical effectiveness of the GLAZE device in terms of the clinical indications listed in the Instructions for Use of the medical device?

1 – very low rating, 5– very high rating

Other indications*

Please indicate your recommendations and evaluation on a scale of 1 to 5.

How long do you assess the durability of the GLAZE product to be – how long does the product remain in the patient's mouth?

Select one answer

How would you assess the retention time of GLAZE in the patient's mouth compared to other materials of a similar type?

Select one answer

How would you assess the following functional characteristics and properties of GLAZE?

(1 – very low, 5 – very high)

How would you assess the consistency of GLAZE when placing:

Select one answer in each line

How would you assess the information on the label or in the instructions for use of GLAZE (indications, method of use, contraindications, adverse effects, warnings, etc.), i.e. is it complete and understandable?

The answer NO should be explained by specifying what information is missing or unclear

What information is missing or unclear?*

During the last 3 years of your professional practice, has the GLAZE ever:

Select one answer in each line.

What kind of allergic reaction did GLAZE cause?*

Have you ever noticed any adverse effects after using GLAZE ?

The answer YES must be justified. What adverse reactions have been observed?

What adverse reactions have been observed?*

Do you assess the GLAZE product as safe in terms of the clinical indications described in the instructions for use?

The answer NO should be explained

Why not?*

What do you usually consider or would consider when deciding to purchase this type of material?

Select one answer

Do you have any comments, suggestions, ideas or concerns regarding the GLAZE medical device that would help us improve our product?

Where do you usually obtain information about ARKONA products?

Select one or more answers
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Dziękujemy za poświęcony czas i udzielone odpowiedzi.