Download 503214-Dental Clearance Form

ST. VINCENT TRANSPLANT SERVICES
DENTAL CLEARANCE FORM
Today’s Date:_________________________
Patient Name:
Patient’s DOB:___________________________
Last Name__________________________ First Name____________________________
Dear Dentist:
This patient is being evaluated for a kidney transplant. A current dental evaluation and treatment of any dental
or periodontal disease is required prior to transplant surgery to reduce the risks of infection associated with
immunosuppressive medications.
Please complete this form, including your findings, recommended treatment plan and prophylactic follow-up
and return to:
St. Vincent Transplant Center
Fax: (317) 583-2491
ATTN: Renal Transplant Coordinators
8333 Naab Road Suite 300
Indianapolis, IN 46260
Dr. Alvin Wee
Program Director
Sara Klingkammer
Pre-Transplant Coordinator
Smyrna Hatfield
Pre-Transplant Coordinator
Arika Hart
Pre-Transplant Coordinator
1. Does the patient have an active oral infection which should be treated? ______________________________
2. Does the patient have nonrestoreable teeth which need extraction? _________________________________
3. Is the patient free of the above?  Yes
 No
4. Other Comments/Plan: ______________________________________________________________________
___________________________________________________________________________________________
___________________________________________________
_______________________________
Signature of Dentist
Date
Please complete the following information (Please Print)
Dentist Name: _________________________________________________________________
Address:______________________________________________________________________
_____________________________________________________________________________
Phone: _______________________________ Fax: ____________________________________
Questions?
Please call St. Vincent Transplant Services at 317.338.6701 or 866.810.2449.
© St. Vincent 503214