Date:
Date:
Dear Dr.: _____________________________________
Address: _____________________________________
Tel.: ________________________________________
Fax.: ________________________________________
Re: Patient: _______________________________
D.O.B. _______________________________
In an attempt to provide the best and safest dental care for this patient, we are requesting medical consultation and authorization. We have enclosed a form that may save you time.
Sincerely,
Drs. Allison, Hulihan, Allison DDS, 15 Aviemore Dr., Pinehurst, NC 28374
Tel.: 910-295-4343; Fax.: 910-295-3913;
Patient’s proposed dental treatment with us:
_________________________________________________________________
Patient reports medical history of:
_______________________________________________________________________
Please consult and check:
_____ Patient must take an antibiotic prior to any dental treatment as well as dental cleanings.
_____Amoxicillin 500mg 4 tabs 1 hour before procedure
_____Clindamycin 300mg 2 tabs 1 hour before procedure
_____Other _______________________________________________
_____Local anesthetic with epinephrine is permissible with dental treatment.
_____Patient is under routine care and recent blood work DATE:_______________ is WNL for systemic disease and medications, including anticoagulant therapy. PT/INR: _______________
_____Restrictions/recommendations are:
_____No restrictions of any kind
Physicians Signature:___________________________ Date;__________________
................
................
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