Study of Dental Amalgam Fillings

Dear All

As a part of our Mercury Free Dentistry campaign we are conducting an online study which involves participation by pregnant women.

The questionnaire of the study is attached herewith.It is self explanatory and can be filled at home.The participants can fill the form either online or in hard copy and send it across.

Its a humble request to all of you to kindly circulate the questionnaire among your friends and colleagues.

If you have any doubt regarding the study, please feel free to contact Dr. Kavita Yadav via email or on mobile.

email:kavita@toxicslink.org : ph:9791123665

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Study of Dental Amalgam Fillings

Note: This study is purely for research purpose only and identity of the participants shall not be disclosed at any point of time. Also the pictures of the fillings are attached for the reference only.

1)      Name:

2)      Age:

3)      Month of pregnancy:

4)      No. of amalgam fillings in mouth:

5)      No. of  other fillings in mouth:

Amalgam filling:   

 

  Other fillings:

                                                       

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