Dental Handle With Care Checklist printable pdf download

Dental Handle With Care Checklist

Patient “Handle with Care” Checklist

Patient Name:

Date:

¨ 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

Dental Handle With Care Checklist