Handle me with care

PATIENT INFO

Handle me with care form

Name *

Surname *

Contact number *

Your email address *

Other concerns I would like to talk about (Please specify):

Yes No

I gag easily.

Yes No

I feel out of control when I am lying down in the dental chair.

Yes No

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.

Yes No

Pain relief is a top priority to me.

Yes No

I don't like injections.

Yes No

I've had a bad reaction to injections.

Yes No

My teeth are very sensitive.

Yes No

I don't like cotton in my mouth.

Yes No

I hate the noise of the drill.

Yes No

I don't like the dental office smells.

Yes No

I have difficulty laying still for long periods.

Yes No

I have difficulty listening and remembering what I hear while sitting in the dental chair.

Yes No

I have health problems and questions that we need to discuss.

Yes No

I don't like being left alone in the treatment area.

Yes No

I have problems with my back.

Yes No

I don't like the chair tipped back too far.

Yes No

I do not like to see dental instruments.

Yes No

I need to talk to you first, without sitting in the dental chair.

By ticking this box I accept the privacy policy and give Dr Hayes and her staff permission to process this information to contact me regarding the Handle me with care form information - POPIA

Enter Code*:

Physical Address

Unit 12
20 Bella Rosa Street
Rosenpark
Bellville, 7530

Contact Us

Tel: 021 910 1457

Email info@hayesdental.co.za

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