Bad Dental Experience E-Form - Advanced Cosmetic Dentistry

Rank Your Fears and Anxiety related to the following List:

1. Strongly Agree

2. Somewhat agree

3. Neither agree or disagree

4. Somewhat disagree

5. Strongly disagree

I have a fear of all dentistry

Dental surgery

Root canals

Fear cosmetic treatments will look fake

Fear there is no treatment for your specific dental problem

Fear you are not being offered the best treatment choices

Fear treatment will take too long or require too many visits

Dental pain

Dental instruments

Dental needle

Sounds of the dental drill

Vibration of the drill

Smell and taste

Gag reflex

Being unable to breathe during dental treatment

Personal Space – uncomfortable with others being too close

Sanitation, cleanliness, and germs

Old outdated dental equipment “Fear it’s not safe”

A bad dental experience as a child

Fear of cost for quality care

Fear insurance will not pay much

I have always had bad teeth. I fear I will be told I have more problems

Have you even taken the time to manage your dental fears, anxiety or pain? (Check any solutions you have tried)

Have you identified and listed your specific dental fears and solutions? Have you ever used self-help strategies to decrease dental pain, fears, and anxiety? Taken the time to research and choose a caring compassionate dentist? Communicated your fears in writing to your dentist? Used relaxation techniques to stay calm during treatment? None of the above

Share the solutions that you found in the past that help to relax you for dental treatments (Check all that apply)

Taking valium Nitrous gas You feel you could only do dental treatment if you were put to sleep for treatment None of the above

Share additional solutions you have discovered which help to reduce your Dental Fairs, Pain, and Anxiety

When Do You Experience Fear & Anxiety? (Check all that apply)

Any time you think of dental treatments The night before dental treatments During dental treatments Any time you talk to a dentist about your of dental treatments Any time the dentists reviews risks or side effects of treatment At home after dental treatments None of the above

Fear Versus Treatment Time (Check all that apply)

Despite doctor recommendations and being offered best treatment options, I will often choose a quick fix short-term solution. I avoid comprehensive dental treatments, which may involve more dental visits. Even if the comprehensive treatments choices are my best options. I avoid going to the dentist at all cost. None of the above

Pre-existing conditions, which may affect your general stress & anxiety (Check all that apply)

OCD -Obsessive compulsive disorder -excessive perfectionism PTSD -Post-Traumatic Stress Disorder -Worry about the unknown when you don’t have complete control of a situation. Claustrophobia, the fear of having no escape, and being closed into a small space “Germophobic” -Phobia of Sanitation, Cleanliness, And Germs Depressive disorders Generalized anxiety disorder Social phobia None of the above

If you had a bad childhood experience, please describe

Wish to stay informed during clinical treatment (Check all that apply)

Desire to maintain control (Check all that apply)

When you are in the dental chair do you feel helplessness and experience an uneasiness related to a loss of control? Is it difficult for you to stay still during dental treatments, which require a longer period of time? None of the above

Physical Closeness (Check all that apply)

Are you uncomfortable with physical closeness of a dental professional or assistant? Have you ever experienced anxiety as a result of claustrophobia? Do you feel like crying when you think of going to the dentist? Do you get increasingly nervous while you're in the waiting room? Do you panic or have trouble breathing when objects are placed in your mouth during a dental appointment? None of the above

Does Your Dental Fear Affect Your Decision Making Ability (Check all that apply)

My Fears do not affect my ability to trust the dentist My Fears slightly affect my ability to trust the dentist My Fears definitely affect my ability to trust the dentist I am so stressed about dentistry that it’s hard for me to make my own decisions. My goal is to find a skilled dentist I can trust to guide me through my treatments. None of the above

Dental fears Versus Treatment Decisions (Check all that apply)

My fears do not affect my ability to make treatment decisions. My fears slightly affect my ability to make treatment decisions. My fears definitely affect my ability to make treatment decisions. When I experience dental fears, it makes it difficult for me to focus on my everyday decision-making. None of the above

Dental Fears Versus Treatment Risks (Check all that apply)

I tend to avoid dental treatments, which involve any amount of risk. Even if it’s only a small risk. I tend to avoid any dental treatments that I do not understand with a 100% certainty I tend to avoid and don’t want to make any dental treatment decisions I tend to avoid and do not want to partake in discussions with the dentist regarding dental treatments recommendations, risks and treatment alternatives, and clinical treatment steps. None of the above

Personal Knowledge about Dentistry (Check all that apply)

I am a researcher and I have a lot of personal experience with the dentist. I read a lot, and double check on the internet to help me make dental decisions. I have a friend or family member who is a dentist or dental lab technician. I always double check with him or her to make sure the correct treatment is offered for my dental problem. I have had several doctors during the past five years. At this point, no dentist has convinced me that they have the skill or ability to fix my dental problems. I’m hoping to find a dentist I can trust. None of the above

The Dentist (check all that apply)

Fears versus Trusting a Doctor (Check all that apply)

I am seeking one caring and skilled doctor who I can trust to help me make my treatment decisions. I often seek second opinions from multiple doctors regarding treatment decisions. None of the above

Dental Problems that “Pop Up” During Treatment

I believe that the treatment results should be predictable for each and every step of treatment. I don’t feel I should have to return to correct unpredicted problems. I understand that in order to achieve excellence, I may need to be flexible: and add treatments and visits as needed. None of the above

Your Viewpoint Regarding Treatment Presentations (Check all that apply)

Patients should communicate their financial concerns before their consultation, so the dentist can customize a specific plan for their budget. I don’t feel comfortable talking with the doctor about finances. I feel it’s more appropriate to speak to the staff member who routinely handles insurance and personal financing. The dentist should offer multiple treatment choices in a Good/Better/Best order. Followed by a cost/benefit for each and then let patients choose what they want. The dentist should offer best treatments first. This should be based on what he would choose for himself. Then follow up with alternative treatment options along with the cost/benefit for each. None of the above

Cost of Dentistry (Check all that apply)

All dentists and dental treatments are the same and should be priced the same. No dentist should charge a higher fee then the fee set by insurance companies. Some dentists provide optimal treatments for patients seeking the highest quality care and are typically more expensive. None of the above

Problems with Your Past Dental Treatments (Check all that apply)

Do you feel as though you received treatments below the Standard of Care? Did another dentist tell that you received treatments below the Standard of Care? Did bad, fake cosmetic dentistry? Promised you excellent results and did not deliver excellent results? None of the above

I seem to have more dental problems than the average person(Check all that apply)

Has another Dentist ever told you why you have more dental problems than the average person?

If you’re dental bonding keeps breaking off (check all that apply)

Types of problems you feel were caused by your former dentist (OPTIONAL)

Solutions offered by your former dentist (Check All That Apply)

The Treating Dentist offered to fix poor outcome The Treating Dentist did not offer to fix the poor outcome You lost confidence in the treating dentist and you left. You did not follow up with treatment. You still like your former dentist but are now seeking treatment to fix the problem None of the above

Staff

Non-caring Poor team work; did not seem to get along with each other or the dentist Treated you like a number Always seemed rushed and overworked None of the above

Billing

Did not explain treatment options or present cost and insurance benefits before treatment began Poorly estimated your co-payment for dental services and then surprised you with a bill after treatment was completed Unjustly sent you to collections The insurance EOB stated that the dentist charged you more than the usual and customary fees. I had good dental insurance that pays for virtually all of the cost for dental treatments None of the above

Scheduling

Could not accommodate your busy work schedule Charged you a missed or cancelled appointment fee Made you wait in the waiting room too long It took too many appointments to finish the work None of the above

Dental Office

The office was dirty The dental equipment was old and outdated I was worried about infection control/disease transmission None of the above

Want to take another step toward exceptional care? Please fill out:

Personal Preferences Patient Communication E-Form

Check Off Items Below To Indicate The E-Forms You Filled Out On Our Website:

Patient Personal Information Form (Faxed to: 312 263-7013) Dental Insurance E-Form (Faxed to: 312 263-7013) Medical Health History E-Form Dental Health History E-Form Cosmetic Questionnaire E-Form Cyber Consult *Send X-Rays & Images Personal Preferences Patient Communication E-Form Pain Management Patient Communication E-Form Patient Satisfaction Survey E-Form

We appreciate your time expressing your past experiences and personal preferences. Your efforts will afford our team to ability to focus on your specific preferences and ultimately provide you with the best dental experience.

If you are a New Patient

You can fill out your new patient paper work now

1. Patient Personal Information Form (Print, Fill Out & Fax or Email)

2. Dental Insurance E-Form (Print, Fill Out & Fax or Email)

3. Medical Health History E-Form

4. Dental Health History E-Form

If you have had a Bad Dental Experience, we strongly recommend you review

Bad Dental Experience Patient Communication E-form

Bad Dental Experience Patient Communication E-Form

Dentistry Phobia’s & Fears

Past Problems with the Dentist & Clinical Treatments

Front Desk Staff “Customer Service” At Previous Office

Summary