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Patient-Dentist Trust & Comfort Contract
Please fill out the following form to help us make you comfortable and take better care of you. After completing it, sign the form. We’ll sign it as well and agree to do our best at addressing each relevant point that you need for your comfort.
Choose all that apply to you.
I know that I have neglected my teeth and I worry what you’ll say or think about me.
Just talking about needles, shots or injections makes me very anxious.
I like to be in control. Being at the dentist makes me feel like I’m giving up control.
I can’t stand being tipped back in the dental chair because it hurts me physically.
I can’t stand being tipped back in the dental chair because I'm very claustrophobic.
I don’t want to feel any pain. I hate pain.
The sound of the drill drives me crazy.
I’m afraid I’ll gag and/or throw up during the appointment.
I want a special hand signal that tells the dentist, “STOP!”
I want to know about my treatment options and what each one involves before we do anything.
During the dental procedure, please keep telling me what you are doing.
Don’t tell me what you are doing at all. I don’t want to know.
I worry that I’ll have a medical emergency (heart attack, seizure, etc.) during treatment.
I want you to know about my health problems before we do anything.
I need to speak with you (the dentist) privately.
Is there any additional information that you believe will make your dental visits better?
Patient's Signature (simply type your name)
Doctor's Signature (simply type your name)
If you want to print the completed page for your records, you must do so BEFORE you send us the form.
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Describe Your Situation
9402 November Dr
St. Joseph, MN 56374
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Curtis Marketing Group | 9402 November Drive | St. Joseph, MN 56374 | (320) 363-0210 | Fax: (320) 363-0218 |
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