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):