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Medical clearance for Dental Treatment. Patient: ______________________________________ DOB: _____________ Dear Dr. ____________________________________, Our mutual patient, _____________________________, is scheduled for dental treatment. Treatment may include: _____ Cleaning (simple or deep) _____ Radiographs _____ Nitrous Oxide _____ Local ...
This article presents recommendations related to patients with certain medical conditions who are planning to undergo common dental procedures, such as cleanings, extractions, restorations ...
Our mutual patient, as noted above, is scheduled for dental treatment at our office. Treatment may include: Cleaning (simple or deep) Radiographs (x-rays) Fillings, Crowns, Bridges. Extraction (simple or surgical) Root Canal Therapy. Periodontal gum surgery.
A Dental Medical Clearance Form is a document requested by dental professionals prior to performing certain dental procedures, like a surgical procedure, that could potentially impact a patient's overall health, especially if they have underlying conditions like coronary artery disease, periodontal disease, oral infections, or other chronic ...
Our mutual patient, as noted above, is scheduled for dental treatment at our office. Treatment may include: Cleaning (simple or deep) Radiographs (x-rays) Fillings, Crowns, Bridges. Extraction (simple or surgical) Root Canal Therapy. Nitrous Oxide. Local Anesthetic (with Epinephrine)
Our mutual patient, as noted above, is scheduled for dental treatment at our office. Treatment may include: Cleaning (simple or deep) Root Canal Therapy. Radiographs (x-rays) Nitrous Oxide. Fillings, Crowns, Bridges. Local Anesthetic (with Epinephrine) Extraction (simple or surgical)
The following treatment is scheduled in our dental office: _____ Please provide any information regarding the above patient's need for antibiotic prophylaxis, current cardiovascular condition, coagulation ability, the history and status of any infectious
In an attempt to provide the best and safest dental care for this patient, we are requesting medical consultation and authorization. We have enclosed a form that may save you time.
Streamline your medical treatment process with our comprehensive dental clearance form. Ensure a smooth journey to treatment. Download now!
MEDICAL CLEARANCE FORM (CONFIDENTIAL) INSTRUCTIONS: Physician – Please complete Section 2, sign and fax / email back to Dentist. SECTION 1 To be completed by the dentist 1. Dental Treatment Plan: _____