Please Handle Me With Care

Name:

Date:

Telephone:

Email:

Put a check mark in the box next to the statement that concerns you or describes your problem. Then share this information with us, your dental team.

I gag easily.

I have not been to the dentist for a long time, and I feel uncomfortable about what may be said 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 that tool that makes the picking and scraping noise. It's like someone is scratching fingernails on a blackboard.

I hate the noise of the drill.

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.

Other:

The Handle Me With Care Partner Pact

I ask that you honestly inform me of all my dental problems. I want you to make me aware of the best quality dentistry available today. Then we can discuss how I can make healthy choices that will work within my budget.

A Handle Me With Care Partnership

Now that you understand the importance of communicating all your fears and any issues of embarrassment and trust, let's look at making a Handle Me With Care Pact between you and your dental professionals.