Dental Handle With Care Checklist


Patient “Handle with Care” Checklist
Patient Name:
¨ I am allergic to latex (please do not use latex gloves)
¨ I am allergic to anesthetic shots (please consult me about an alternative local anesthetic)
¨ I cannot have metal fillings
¨ I cannot have porcelain fillings
¨ I gag easily (and would like to speak to you about a numbing agent)
¨ Dental work makes me anxious
¨ Shots make me anxious (please use a local numbing agent first)
¨ Leaning far back in a dentist chair makes me anxious
¨ I have muscle/back/neck issues and would like a pillow and time for readjustments
¨ The sound of cleaning/scraping tools makes me anxious (please provide or allow headphones)
¨ I don’t want to see the tools or shots
¨ I don’t like cotton in my mouth
¨ I have sensitive teeth
¨ I don’t want the following flavors used: _______________________________
¨ I would like the dentist to outline every detail of the work being done before proceeding
¨ I would like an outline of full costs before proceeding


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Parent category: Medical