JASMINE SUNG DDS

6918 Corporate Dr. Ste. A-11 Houston, TX 77036

(713) 777-1221

MEDICAL CONSULTATION REQUEST

First Name:

To Dr. (first):

Last Name :

(last)

MI:

(middle)

RE:

Vital Signs: BP

Pulse

Birth Date:

Please complete the form below and return it to:

Phone:

Fax:

E-Mail Address:

Our patient has presented with a history of the following medical problem(s):

High Blood Pressure

Diabetes

Stent

Cardiac Disease/Surgery

Recent CVA/Stroke

Bisphosphonate Therapy

Cancer treatment

Multiple meds.

Prosthetic joint replacement

Other

If Other, explain:

The following treatment is scheduled in our office:

General Dentistry

Extractions

Gum Surgery

Implant Surgery

Other

If Other, explain:

Most patients experience the following with the above planned procedures:

Bleeding:

minimal significant

Stress/Anxiety:

low medium high

Dentist Signature

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PHYSICIAN - PLEASE COMPLETE THIS SECTION

Please provide any information regarding the above patient’s need for antibiotic prophylaxis, current cardiovascular condition, coagulation ability, and the history and status of infectious diseases. Ordinarily, local anesthesia is obtained with agents containing a vasoconstrictor. For some surgical procedures, the vasoconstrictor concentration may be increased to 1:50,000 for hemostasis. The vasoconstrictor dose NEVER exceeds 0.2 mg total.

CHECK ALL THAT APPLY

OK to PROCEED with dental treatment; NO special precautions and NO prophylactic antibiotics are needed.

Antibiotic prophylaxis IS required for dental treatment according to the current American Heart Association and/or American Academy of Orthopedic Surgeons guidelines.

Other precautions are required

Please list

DO NOT proceed with treatment.

Please give reason

Patient has an infectious disease:

Aids (please provide current lab results)

Hepatitis

Type

acute carrier

TB (ppd+/active)

Other

If other, explain

Requested relevant medical and/or laboratory information is attached.

Treatment may proceed on (date)

Treatment may proceed on (date)

Physician Signature

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PATIENT CONSENT

I agree to the release of my medical information to the office of the above named dentist.

Patient Signature

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