Please Handle Me With Care - Port Warwick Dental Arts
Please Handle Me With Care
Put a check mark in the box next to the statements that concern you or describe how you feel. Then share this information with your dental team.
( 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 you 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.
❑ 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.
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Experienced, artistic, compassionate hands
251 Nat Turner Boulevard · Newport News, Virginia 23606
Telephone 757/223-9270 · Fax 757/223-9264
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