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Medical Clearance request for: _________________ Date: ______________ Dear Dr. ________________________________ Your patient _________________________has been evaluated in our office and we are planning a dental procedure. ________________needs medical clearance before we will schedule the procedure. The procedure will be approximately ________________ in duration and will be performed under ____________anesthesia. We plan to prescribe the following medications: ____ We understand that you manage the patient’s________. Please advise ________________ how you would like for him/her to manage his/her ___________ as soon as possible. Also, please write the instructions below that you have reviewed with the patient. Once everyone is aware of the appropriate pre-procedure instructions, we will schedule ______________’s procedure. ____We understand that you manage the patient’s __________. Please advise ________________how you would like for him/her to manage his/her ________medications. Please write the instructions you have reviewed with the patient. Once everyone is aware of the appropriate pre-procedure instructions, we will schedule _____________’s procedure. ___ Please list all current medications taken by this patient: _________________________________________________ ___If there are any other special precautions and/or recommendations (i.e.: medical management before or during the procedure), please list them: ___ Please perform the following labs or diagnostic tests: YES or NO (please circle) The patient IS medically cleared for the above procedure YES or NO (please circle) The patient IS NOT medically cleared for the above procedure and requires further medical evaluation. ___________________________________________ ______________________________________ Attending Physician’s Name Signature of Attending Physician Please Fax the completed and signed Medical Clearance form to our Office at 972-594-4839 and then mail the original Thank you, My DFW Dentist 2820 N O’Connor Irving, TX 75062 972-594-4888 Fax 972-594-4839