Dental Comfort Preferences Form
Share your comfort and treatment preferences to help us tailor your dental experience.
Full Name
*
First Name
Last Name
Preferred Contact Method
*
Email
Phone Call
Text Message
Preferred Appointment Time
Please Select
Morning (8am–12pm)
Afternoon (12pm–4pm)
Evening (4pm–7pm)
No Preference
How do you feel about dental visits?
*
Very Comfortable
Somewhat Comfortable
Neutral
Somewhat Anxious
Very Anxious
What helps you feel more comfortable during dental visits? (Select all that apply)
Noise-cancelling headphones
Blanket
Music
Aromatherapy
Short breaks during treatment
Other
Please rate your sensitivity to pain during dental treatment.
*
Not Sensitive
1
2
3
4
5
6
7
8
9
Extremely Sensitive
10
1 is Not Sensitive, 10 is Extremely Sensitive
Do you have any preferences for numbing or sedation?
No preference
Numbing gel only
Local anesthesia
Open to sedation options
Are there any sounds, tastes, or sensations you wish to avoid?
How do you prefer to be updated about your treatment progress?
Brief explanations during treatment
Detailed updates before and after treatment
Only if something changes
Is there anything else you’d like us to know to make your visit more comfortable?
Submit Preferences
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