Dental Office Name
Patient Name: ___________________________ DOB: ____________
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:
Please fax this completed form to:
______________ __________________ ____________
Physician name Physician Signature Date
______________ ___________________ ____________
Dentist Name Dentist Signature Date