Audubon Dental Group
6120 Magazine St.New Orleans, LA 70118-5826p. 504-891-7471f. 504-891-8919Medical Clearance for Dental TreatmentDate:_______________________Attn:_______________________Patient:____________________________________DOB: __________________Dear Dr. ___________________________________Our mutual patient, ___________________________________________ is scheduled for dental treatment.Treatment may include:___ Cleaning (simple or deep)___Root Canal Therapy___ Radiographs___Nitrous Oxide___ Fillings, Crowns, Bridges___ Local Anesthetic (with epinephrine) ___ Extraction (simple or surgical)___Other: __________________________The patient has indicated the following medical conditions:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please evaluate this patient’s medical history and advise us of any special considerations that should be made.Antibiotic Prophylaxis:Yes___No___Interruption of anticoagulants:Yes___No___ How long before and after treatment? _________________________Anesthetic Restrictions:Yes___No___ Is epinephrine OK?:Yes___No___Type of Antibiotic Allowed/Recommended: _______________________________ Any additional comments? __________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Physician (please print) ______________________________________________________________________Physician Signature ___________________________________________________________________________We appreciate your assistance in providing optimum care for this patient. Please have physician sign and fax to above. ................
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