Download Medical Clearance request for

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