MEDICAL CONSULTATION REQUEST
MetLife MEDICAL CONSULTATION REQUEST University of the Pacific
To: Dr.__________________________________ Please complete the form below and return it to
Dr.________________________________
_________________________________ ______________________________________
RE: __________________________________ ______________________________________
__________________________________
Date of Birth Phone#________________________________
Fax#__________________________________
Our patient has presented with the following medical problem(s):___________________________
________________________________________________________________________________
________________________________________________________________________________
The following treatment is scheduled in our clinic:___________________________________________________________________________
________________________________________________________________________________
Most patients experience the following with the above planned procedures:
bleeding: • minimal (50ml)
stress and anxiety: • low • medium • high
_________________________________ _____________________
Dentist’s signature Date
PHYSICIAN’S RESPONSE
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 2% Lidocaine, 1:100,000 epinephrine. For some surgical procedures, the epinephrine concentration may be increased to 1:50,000 for hemostasis. The epinephrine 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)________________________________
_______________________________________________________________________________
Treatment may proceed on (Date)_________________
• Patient has an infectious disease:
• AIDS (please provide current lab results) • Hepatitis, type ______, (acute/carrier)
• TB (PPD+/active) • Other (explain)___________________
• Requested relevant medical and/or laboratory information is attached.
____________________________________ _____________________
Physician Signature Date
PATIENT CONSENT
I agree to the release of my medical information to the University of the Pacific School of Dentistry.
___________________________________ ___________________
Patient Signature Date
This Medical Consultation form is created and maintained by the University of the Pacific School of Dentistry, San Francisco, California
Support for the translation and dissemination of the Health Histories comes from MetLife Dental Care.
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- confidential new patient information form trimac dental
- antibiotic prophylaxis against infective endocarditis ie
- antibiotic prophylaxis against infective endocarditis
- dental hygiene act 1991 o reg 501 07
- medical consultation request
- foreword scottish dental clinical effectiveness programme
- antibiotic prophylaxis to prevent infective endocarditis
- canadian society of transplantation canadian society of
- bacterial endocarditis washington state dental
Related searches
- consultation about breast reduction surgery
- free lawyer consultation phone number
- free phone consultation lawyer
- printable request for medical records
- medical records request form pdf
- online consultation for erectile dysfunction
- free legal consultation by phone
- online doctor consultation with prescriptions
- free legal consultation near me
- free consultation lawyers near me
- free consultation divorce lawyers near me
- icd 10 consultation visit