Medical Clearance for Dental Treatment

Date:

Attn:

Patient:

Birthdate:

Dear Dr. :

Our mutual patient,

is scheduled for dental treatment.

Treatment may include:

Cleaning (simple or deep)
Radiographs
Fillings, Crowns, Bridges
Extraction (simple or surgical)
Root Canal Therapy
Nitrous oxide
Local anesthetic (with epinephrine)
Other-local

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

YesNo

Interruption of anticoagulants:

YesNo

How long before and after treatment:

Anesthetic restrictions:

YesNo

Is Epinephrine OK?

YesNo

Type of antibiotic allowed/recommended:

Type of pain medication allowed/recommended:

Any additional comments:

Physician Name (please print)

Date: