Medical Clearance Form

Date:

Patient Name:

Telephone No.:

Date of Birth:

Social Security Number:

Indicate INR #:

Physician's Name:

Contact Phone Number

Fax:

Planned dental procedures may include x-rays, subgingival cleanings, fillings, root canals, extractions.

Is the Patient an Acceptable Candidate for the above procedure?

Yes No

Should Prophylactic Antibiotics be prescribed?

Yes No

If yes, which one?

Dispense:

Can local anesthesia with epinephrine (1:100,000) be used?

Yes No

If the patient is taking anticouglant drugs: (example: plavix, coumadin, ext.)

Anticouglant medicine can be discontinued (Please indicate number of days) before the dental procedure.

and resumed within (Please indicate number of days) after the dental procedure.

Any other precautions to be taken:

Physician's Signature:

Date:

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