Dental Office Name
Dentist Name


Patient Name: ___________________________  DOB: ____________


Dear ______________________,

The above named person is a patient at our dental office.  We need to consult with you regarding the following matter(s).  Please review the checked areas below, write your recommendations, and return to our office as soon as possible to prevent delays in treatment.  Thank you so much for your time and attention.


_____ Does this patient require subacute bacterial endocarditis prophylaxis?

                        _______ Yes   _______ No

_____ This patient was unable to provide an accurate and thorough medical history.  Please provide a full health history plus a current medication list. 


____Do you feel that the patient can tolerate the following procedures without serious or undue complications?



            ______ Yes     _____ No        Comments:


Other consult:


Please fax this completed form to:


______________                    __________________                                   ____________
Physician name                       Physician Signature                                         Date                                       


______________                    ___________________                                  ____________
Dentist Name                          Dentist Signature                                            Date