Medical Clearance Form For Dental Treatment

To:

PH:

FX:

Patient(Last Name):

(Middle Name)

(First Name)

DOB:

Email:

Dear Dr.:

Antibiotic (pre-medication):

Yes No

Interruption of anticoagulants:

Yes No

How long before and after treatment:

Anesthetic restrictions:

Yes No

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

Medical Clearance Form for Dental Treatment