Dental Clearance Letter

Name
Address
City, State ZIP
(or preferably print on letterhead)

Dental Clearance Letter — Please Give To Your Dentist

DATE

Re: __________________________________________ DOB: ______________________

To Whom It May Concern:

We have requested that the above candidate provide us with documentation of their current dental health status. This letter will be an important part of the application process.

Please complete the area below, and return this letter to us as soon as possible.

Sincerely,

(Name)
(Address)
(Fax number)


Date of last dental exam: _____________

__ Applicant has no current dental problems that need treatment.

__ Applicant has dental conditions that have not been treated.

Dentist name (please print): _________________________________

Dentist signature: _________________________________________

Date: __________________________