Physician Clearance For Dental Treatment Form
ADVERTISEMENT
1KAISER & ROSEN DENTAL ASSOCIATES
8911 Krewstown Road
Philadelphia, PA 191115
(215) 464-5600
Fax (215) 464-5083
PHYSICIAN CLEARANCE FOR DENTAL TREATMENT
Dear Doctor,
__________________________________was seen by our dental service and the following was
noted:__________________________________________________________________.
Our proposed treatment plan for this patient includes:_______________________________________
__________________________________________________________________________________.
In view of this patient's medical history, and in order that our mutual patient receive optimal
healthcare, would you please respond to the question(s) below. This patient cannot be scheduled for
further care until we receive this form from your office.
Thank you in advance for your help and
cooperation.
Sincerely,
__________________________________________________DDS / DMD
Dental Service Provider
1)
(a) Should this patient be premedicated with an antibiotic if at risk for Bacterial Endocarditis?
YES (
) NO (
)
(b) If so, current American Heart Association regimen?) YES (
)
NO(
)
(c)
If "YES" , please indicate the condition necessitating premedication:
( ) Vegetative Heart Murmur ( ) History of Rheumatic Fever ( ) Artificial Heart Valve
( ) Recent Heart attack
( ) Recent Cardiac Surgery
( ) Pacemaker
( ) Mitral Valve Prolapse
( ) Vascular Surgery
( )Prosthetic Devices
( ) Other:________________________________________________
2)
Are there any Contraindications to the use of:
(a) Local Infiltration Anesthesia (Lidocaine 2%)
Yes ( ) No( )
(b) Epinephrine 1:100,000 (0.01mg/ml)
Yes ( ) No( )
(c) Dental Radiographs
Yes ( ) No( )
3)
Does this patient need to have medication levels modified prior to dental treatment?
(ie: Anticoagulant therapy)
YES______
NO______
4)
Patient's current medical condition (ie: Is this patient medically stable?)
_____________________________________________________________________
_____________________________________________________________________
5)
Current medications (please include dosage and frequency):____________________
_____________________________________________________________________
_____________________________________________________________________
6)
Contraindications or recommendations prior to dental treatment:_________________
_____________________________________________________________________
7)
Do you feel further consultation is necessary?
Yes ( ) No ( )
Physician's Name:_____________________________________Date:_________________________
Office Address:______________________________ Office Phone: (______)______-_____________
Physician's Signature:________________________________________________________
(**Please instruct patient to return this form to the dental office prior to treatment or please mail this to the
above address. Thank you for your time and cooperation.)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business