Handle Me With Care

 I gag easily.

 I feel out of control when I am lying down in the dental chair.

 I have not been to the dentist for a long time and I feel uncomfortable about what will say

or think about my teeth and my dental hygiene.

 I know I have bad habits that are causing harm to my dental health. I am afraid I might

not be able to break them.

 Pain relief is a top priority to me.

 I don't like shots, or I've had a bad reaction to shots.

 Please tell me what I need to know about my mouth so I can make an informed decision.

 My teeth are very sensitive.

 I don't like the sound of that tool that makes the picking and scraping noise.

 I don't like cotton in my mouth.

 I hate the noise of the drill.

 I don't like the dental office smells.

 Please respect my time. I don't want to be left sitting in the reception area.

 I want to know the cost up front. No money surprises, please.

 I have difficulty listening and remembering what I hear while sitting in the dental chair.

 I have health problems and questions that we need to discuss.

 I don't like being left alone in the treatment area.

 I have problems with my back.

 I don't like the chair tipped back too far.

 I do not like to see dental instruments.

 I need to talk to you first, without sitting in the dental chair.

 Other concerns I would like to talk about (Please specify):