REQUEST FOR DENTAL TREATMENT
Ramapo Oral and Maxillofacial Surgery, P.C.
180 Ramapo Valley Road (Route 202) Oakland, NJ 07436
Tel. 201-337-3797 / Fax. 201-337-8845
PERI-OPERATIVE RECOMMENDATION
REQUEST FOR DENTAL TREATMENT
Patient:________________________________
Date:_________________
Pt's DOB: ______________
Procedure to be done:__________________________________________________________________
Dear Dr._______________________:
The above named patient is scheduled for oral surgery with or without IV anesthesia in our office on _________________. Peri-operative recommendation is required before we can perform the surgery. Please review this patient's medical history and complete the following.
1. Does the patient require pre-medication? YES
NO
2. Are NSAIDS contraindicated?
YES
NO
3. Are narcotic analgesics contraindicated?
YES
NO
4. May the patient stop blood thinner,(Aspirin, Coumadin, Plavix)
If so, how many days?____________________
5. Is the patient taking oral BISPHOSPHONATES YES
NO
Instructions for further treatment:
Patient's Medical History
List All Past Surgeries:
_____________________________
___________________________
_____________________________
___________________________
_____________________________
___________________________
_____________________________
___________________________
_____________________________
___________________________
Please List Medications:
_____________________________
___________________________
_____________________________
___________________________
_____________________________
___________________________
_____________________________
___________________________
_____________________________
___________________________
Signature _______________ Doctors Name: ___________________________
Phone Number : ___________________________
***PLEASE FAX BACK TO OUR OFFICE AS SOON AS POSSIBLE. *** Thank you,
Anup Muduli, D.M.D
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