Uptown New Orleans Dentist | 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. ................
................
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
- o grady orthopaedics
- 865 return to duty after absence for medical reasons
- welsh mountain welsh mountain
- patient ed template 2
- transgender care
- medical certificate format letter formats
- important information about tumescent liposuction
- uptown new orleans dentist audubon dental group
- preoperative history and physical
Related searches
- new orleans lions club
- new orleans hip hop nightclubs
- nightlife in new orleans tonight
- new orleans nightlife pics
- new orleans last names
- new orleans last names french
- new orleans french names
- new orleans baby names
- new orleans names for boys
- new orleans names for girls
- common new orleans last names
- new orleans family names