Handle Me With Care

First Name

M.I.

Last Name

I gag easily.

I feel out of control when I'm lying down in the dental chair.

I have not been to the dentist for a long time, and I feel uncomfortable about what you will say about my teeth and dental hygiene.

Pain relief is a top priority for 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 in order to make an informed decision.

My teeth are very sensitive.

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

I don't like cotton in my mouth.

I hate the noise of the drill.

Please respect my time. I don't want to be left sitting.

I want to know the cost of front. No money surprises please.

I have difficulty listening and remembering what I hear when sitting in a dental chair.

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