This is what I brought in to my dentist and it is tailored for my needs/level of sensitivity. You will need to modify it, but it’s a good place to start.
Allergy Info for ______________
Products to use/not use:
– Please use only powder-free gloves.
– No topical anesthetic please, it contains a corn derivative.
– I need to provide my own cup and water for rinsing.
– I have brought my own unwaxed floss and toothpaste. Please only use those.
– Please, no mouthwash/mouth rinse, only water!
– Please don’t apply anything to my lips using q-tips. I have my own “safe” lip balm that I can apply myself, no q-tip, if needed.
– Injected anesthetic: Please use only Carbocaine.
– I have reacted before to highly processed corn derivatives such as sorbitol and citric acid, as well as to plastic and waxed paper cups. My first point of reaction is always my mouth and throat: tongue swelling, difficulty swallowing, sometimes lip swelling. In extreme cases I will have an asthma attack. Since my mouth will be numbed, I may need your help to watch out for swelling if we’ve missed anything about the ingredients or products used. (Beth has been very thorough, I hope we will be fine.)
– I have taken 25mg of Benadryl to head off any possible reactions. I will likely be a bit sleepy but not completely out of commision. My boyfriend will pick me up when the appointment is over.
– If there is a swelling reaction, I have an additional 25mg benadryl pill that I can take- prefer not to take it though, as it *will* put me to sleep. If my airway begins close off, I will need to use my epi-pen and then go to the emergency room.