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Dentist Medical Clearance Form
Date*
Dental Office Name*
Address*
Street Address 1
Street Address 2

City

State/Province/Region

Postal/Zip Code

Country
Phone*
--
Fax*
--
Patient Name*
Address*
Street Address 1
Street Address 2

City

State/Province/Region

Postal/Zip Code

Country
Phone*
--
Our mutual patient is in need of dental procedures. Due to recent treatment with your office, we request that you please assess his/her medical condition and return this form to us via fax. Thank you.
Date of Report*
Physician Name*
Office Address*
Street Address 1
Street Address 2

City

State/Province/Region

Postal/Zip Code

Country
Phone*
--
Fax*
--
Date of Treatment*
Type of Treatment*
Is patient still receiving treatment?*
Yes No
List all known medical conditions.*
List all current medications.*
List known drug allergies.*
List any medications that must be STOPPED prior to and/or after dental treatment.*
List any medications that must be PRESCRIBED prior to and/or after dental treatment.*
List any anesthesia restrictions.*
Can epinephrine be used during dental treatment?*
Yes No
Is pre-medication required?*

Yes No

Please list the medication and reason.
Additional comments.
Dentist's comments.

Dentist Medical Clearance Form