Let your dentist know about your dental care preferences

Date completed:

Your full name:

Your preferred name:

Your email:

Date of birth:

Your dental practice of service:

Who supports you with decision making:

Do you have a Lasting Power of Attorney for health?:
YesNo

Please tell us about any problems you have with your teeth or mouth:

Please tick one box for each statement:

It's important to me that my teeth look good:
DisagreeAgreeUnsureI'd like to discuss this with my dentist

I want my teeth to be left alone if they are not causing me pain:
DisagreeAgreeUnsureI'd like to discuss this with my dentist

I am happy to sit in the dental chair for as long as it takes to fix a broken tooth:
DisagreeAgreeUnsureI'd like to discuss this with my dentist

Visiting the dentist makes me scared or anxious:
DisagreeAgreeUnsureI'd like to discuss this with my dentist

I don't mind having teeth removed if it means I have less pain:
DisagreeAgreeUnsureI'd like to discuss this with my dentist

I would want dentures to replace missing teeth if possible:
DisagreeAgreeUnsureI'd like to discuss this with my dentist

Being able to eat whatever I want is important to me:
DisagreeAgreeUnsureI'd like to discuss this with my dentist

Please use the space below to tell us more about your answers above or write any questions you have for the dentist:

Once you click submit below we will email you a copy of your completed Dental Decisions Tool. You can forward this to your dentist or print it to take with you to your next visit.

You can talk to the dentist about these answers and anything else concerning your treatment during your next visit.