Medical Clearance Form

Patient Information

Name

Date of Birth

Physician of Record Information

Name

Phone

Fax

Dear Doctor:

Our mutual patient (listed above) is scheduled for dental hygiene and/or dental treatment appointment. Patient indicates a medical concern of:

Physician to Complete Section Below

Please evaluate this patient's medical history and advise us on any special considerations that should be made for this patient with regard to the dental hygiene and/or dental treatment.

Would you recommend any treatment modifications for this patient?

Yes

If yes, specify

Is antibiotic prophylaxis necessary?

Yes

If yes, specify

May local anesthetic be used on this patient?

Yes

If yes, specify

Additional comments:

Physician

Physician Signature

Date Signed

Thank you for your assistance in providing optimum care for this patient.

The information contained in this transmission is doctor-privileged and confidential. It is intended only for the use of the individual or entity to which it is addressed. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is prohibited. If you have received this communication in error, please immediately notify us.

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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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