Dental Amalgam Program 2015 Annual Report

Annual Report January 1, 2015 through December 31, 2015

    ***Important tips for filling out your annual report.***

    This survey should not take longer than 20 minutes to complete. Before starting, please gather all dental amalgam and spent fixer solution records for reporting. For each dentist on site, have name, dental license number, and schedule available. If you have any questions, please visit or call (408)793-5300. You will be prompted to print, sign, and submit your annual report. Please submit the printout of the signature page to the Dental Amalgam Program, 200 E. Santa Clara St, 7th Floor, San Jose, CA 95113 OR FAX at (408) 271-1930. A copy of the completed form will be emailed to your email address.