Your Concern is Ours

We are here to help, and are attentive to your needs.  Print out this form, put a check mark next to the statements that concern you or describe how you feel. Please share this or any other information with your dental team. We will help you.

  • 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 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.
  • Other (Describe)_______________________________

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