Medical Consultation Form:

Patient _______________		Date _________
Address _______________
______________________
Dear Dr. ___________________________
The above named patient is seeking dental care in our office. In order to provide the best care possible, it is necessary that we know the following information. The patient indicates a history of:
___ hypertension		___ adrenal insufficiency or steroid therapy
___ cardiovascular accident		___ rheumatic heart disease
___ prosthetic heart valve		___ heart murmur
___ mitral valve prolapse		___ systemic-pulmonary artery shunt
___ endocarditis		___ drug allergies
___ anemia		___ hepatitis A or B (circle one)
___ renal disease		___ leukemia
___ pulmonary disease		___ renal dialysis with shunts
___ diabetes		___ liver disease
___ systemic lupus eythematous		___ anticoagulant therapy
___ Marfan's syndrome		___ prosthetic joint
___ chemotheraphy		___ radiation therapy to head and neck
___ HIV		___ pacemaker, type _________
___ prescription diet drugs		___ other __________________________
(i.e Pondimin/phentaramine combination)
Treatment to be performed on this patient includes:
___ oral surgical procedures including extractions
___ deep scaling and root planing
___ dental radiography
___ endodontic treatment (root canals)
___ local anesthetics (topical and injectible)
___ oral prophylaxis (to include some removal of epitheliat tissue)
Possible considerations are:
___ bleeding with transient bacteria
___ prolonged bleeding
___ pacemaker interference due to use of ultrasonic scaling devices
___ other
We are requesting a medical consultation for this patient. Please indicate appropriate response below.
1. This patients current medications include: ____________________________________________
2. This patient requires no prophylactic antibiotic premedication regimen for the indicated procedures. ________
3. This patient requires prophylactic antibiotic coverage for the prescribed dental procedures. Please indicate regimen if other than standard AHA regimen. ___________________________________________________
4. This patient may not receive dental treatment at this time.
5. This patient may receive limited dental treatment at this time.
6. Comments: Please use reverse side.
Date: _______________		Physician's Signature _____________