Dental Practice Accommodation Request Form

Accessible Dental Care: Request Accommodations for Your Comfort and Safety

Every patient deserves dental care that respects their individual needs and circumstances. Whether you experience dental anxiety, have physical positioning requirements, or need specific communication methods, our Dental Practice Accommodation Request Form helps you communicate your needs clearly before your appointment—so we can provide the best possible care in a comfortable, safe environment.

Why Accommodation Requests Matter in Dental Care

Dental visits can be challenging for many people. From sensory sensitivities and mobility limitations to communication barriers and anxiety disorders, numerous factors can make standard dental appointments difficult or even impossible without proper accommodations. By submitting your accommodation needs in advance, you give your dental team the opportunity to prepare, adjust their approach, and create an experience tailored to your specific requirements.

This form is designed for patients who need:

• Anxiety management support – including sedation options, breaks during procedures, distraction techniques, or the presence of a support person
• Physical positioning accommodations – such as wheelchair accessibility, customized chair positioning, transfer assistance, or cushioning for comfort
• Communication preferences – including written instructions, visual aids, sign language interpretation, or alternative communication methods
• Sensory accommodations – like dimmed lighting, reduced noise, scent-free environments, or weighted blankets
• Medical equipment coordination – for patients who need oxygen, feeding tubes, or other assistive devices during treatment

How This Template Helps Dental Practices and Patients

Built with Paperform, this template makes the accommodation request process simple, respectful, and efficient for both patients and dental practices. Patients can submit their needs clearly and comprehensively, while dental teams receive organized, actionable information that helps them prepare appropriately.

For patients, the form provides:

• A safe, private way to communicate sensitive needs
• Comprehensive options covering physical, sensory, communication, and emotional accommodations
• The ability to explain specific requirements in detail
• Confirmation that their needs have been received and will be addressed

For dental practices, the form enables:

• Advanced notice to prepare rooms, equipment, and staff
• Better appointment scheduling to allow extra time when needed
• Improved patient satisfaction and treatment outcomes
• Documentation for compliance with ADA and accessibility requirements
• Reduced no-shows and anxiety-related cancellations

Key Features of This Dental Accommodation Form

This template includes sections for:

1. Patient information and appointment details – Basic contact information and the scheduled appointment date
2. Anxiety and comfort management – Options for sedation preferences, support person presence, appointment timing, breaks, and distraction methods
3. Physical positioning and mobility needs – Wheelchair accessibility, transfer assistance, positioning preferences, and cushioning requirements
4. Communication preferences – Preferred communication methods, interpretation needs, and instruction formats
5. Sensory accommodations – Lighting, sound, scent, and tactile sensitivities
6. Medical equipment and devices – Coordination for oxygen, feeding tubes, or other assistive technology
7. Additional needs – Open space for any other requirements not covered above

The form uses conditional logic to show relevant follow-up questions based on initial selections, keeping the experience streamlined while gathering comprehensive information.

Perfect for Dental Practices Committed to Inclusive Care

This accommodation request form is ideal for:

• General dental practices serving diverse patient populations
• Pediatric dentists working with children who have special needs
• Dental clinics committed to ADA compliance and accessibility
• Specialty dental practices (orthodontics, oral surgery, periodontics)
• Community health centers providing care to underserved populations
• Geriatric dental programs serving older adults with mobility or cognitive needs

Streamline Your Accommodation Process with Paperform

With Paperform, you can customize this template to match your practice's specific capabilities and brand. Add your logo, adjust colors to match your website, and modify questions to reflect the accommodations you can realistically provide. The form can be embedded directly on your patient portal or appointment scheduling page, or shared via a custom link.

Extend functionality with integrations:

• Connect to your practice management software to attach accommodation notes directly to patient records
• Send submissions to Google Sheets or Airtable for tracking and follow-up
• Trigger email notifications to dental assistants, office managers, or specific providers
• Use Stepper workflows to automatically route accommodation requests to the appropriate team member, schedule follow-up calls, and create preparation checklists for the appointment day

For practices using Papersign, you can follow up accommodation approvals with consent forms or treatment agreements that patients can sign electronically, keeping all documentation organized and linked to the original accommodation request.

Building Trust Through Accessibility

Providing accommodations isn't just about compliance—it's about building trust with patients who may have had negative dental experiences in the past. When patients see that you've thoughtfully considered their needs and taken steps to accommodate them, they're more likely to keep appointments, communicate openly, and continue their dental care.

This form template demonstrates your commitment to inclusive, patient-centered care. It signals that you understand the diverse needs of your community and that you're willing to adapt your standard procedures to ensure everyone receives quality dental care.

Get Started Today

Whether you're a solo practitioner or part of a larger dental group, implementing a structured accommodation request process improves patient outcomes and practice efficiency. This Paperform template gives you a professional, compassionate starting point that you can customize and deploy in minutes—no coding required.

Start collecting accommodation requests today and create a more welcoming, accessible dental practice for all patients.