Medical Release Form

Pediatric & Adolescent Dentistry and Orthodontics

Please correct the errors described below.

In our continuing efforts to ensure the safety of our mutual patient, we request your response to our medical release form. Please provide us with the information and any suggestions or comments you may have. If you would like to discuss any particular aspect of the planned treatment, please call our office at (619) 440-5915 or Fax (619) 440-0605.

Dentist: Gary A. Olen, D.D.S., M.S., Inc. & Michael Maurer, D.D.S., M.S., Inc.

Patient Name:

Dental Diagnosis:

Medical History of Concern:

** Does patient's medical condition require any special precautions before dental treatment can be rendered?

Yes No

Comments:

** Does patient require prophylactic pre-medication with antibiotics?

Yes No

If yes. choice and dosage of drug:

** Can dental treatment be administered to the patient without risk to patient's health?

Yes No

** Can the Local anesthetics be administered?

A. Lidocaine 2% with epinephrine 1:100,000

Yes No

B. Citanest Forte 3% with epinephrine 1:200,000

Yes No

C. Carbocaine 3% without epinephrine

Yes No

D. Citanest Plain 4% without epinephrine

Yes No

** Can x-rays be taken?

Yes No

Is there anything else that we should know about the patient's health that would be significant to dental tx?

Yes No

If Yes, what?

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Physician Name:

Phone #:

Physician's Signature:

Date:

Your information will be encrypted.

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