Medical Clearance for Dental Treatment





    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


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


    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.