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Office of Keerthi Senthil DDS, MS

72027 Desert Drive, Rancho Mirage, CA 92270

(760) 340-5107

Medical Clearance Form for Dental Treatment

To:
PH:
FX:
Patient(Last Name):
(Middle Name)
(First Name)
DOB:
Email:
Dear Dr.:

The patient has indicated the following medical conditions:

Please evaluate this patient's medical history and advise us of any special considerations that should be made.

Treatment may include:

Cleaning (simple or deep)
Fillings, Crowns, Bridges
Local anesthetic (with epinephrine)
Extraction (simple or surgical)
Radiographs
Root Canal Therapy
Nitrous Oxide/Conscious Sedation

Senthil DDS, MS and/or Rajesh Swamidass DDS


Do you recommend the following?

How long before and after treatment:
Type of antibiotic allowed/recommended:
Type of pain medication allowed/recommended:
Any additional comments:

Physician Name (please print):
Date:
Physician Signature:

Use your mouse cursor or the tip of your finger to sign above


We appreciate your assistance in providing optimum care for this patient. Thank you.


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