Medical Clearance for Dental Treatment

    Date:


    Attn:


    Patient:
    Birthdate:


    Dear Dr. :


    Our mutual patient,
    is scheduled for dental treatment.


    Treatment may include:








    Please evaluate this patient’s medical history and advise us of any special considerations that should be made. Antibiotic PROPHYLAXIS:
    Interruption of anticoagulants:


    How long before and after treatment:


    Anesthetic restrictions:


    Is Epinephrine OK?


    Type of antibiotic allowed/recommended:


    Type of pain medication allowed/recommended:


    Any additional comments:


    Physician Name (please print)


    Physician Signature


    Date:


    We appreciate your assistance in providing optimum care for this patient. Please have physician sign and fax to:


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    GentileDentalCare

    A prosthodontist is a dentist who specializes in the esthetic restoration and replacement of teeth.

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    Our staff is professional and courteous with everyone who walks through our doors. We strive to give exemplary care in our practice by communicating with our patients and agreeing on a treatment plan that best suits them aesthetically, and financially.

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