Cardiac Clearance Request for Oral Surgery

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Clinic Name
Clinic Address
Clinic Phone Number
Clinic Email

Cardiac Clearance Form for Oral Surgery

Patient Information:

  • Patient's Full Name: _______________________________________________
  • Date of Birth: ____________________________________________________
  • Gender: _________________________________________________________
  • Address: ________________________________________________________
  • Phone Number: ___________________________________________________

Reason for Oral Surgery:

Brief description of the oral surgery procedure requiring cardiac clearance:

Cardiac History:

Please provide information regarding the patient's cardiac history, including but not limited to:

  • History of heart disease (e.g., coronary artery disease, arrhythmias, valvular heart disease):
  • Previous heart surgeries or procedures:
  • Cardiac medications (current and past):
  • History of heart attacks (myocardial infarction), strokes, or transient ischemic attacks (TIAs):
  • Presence of pacemakers or other implanted cardiac devices:
  • Any other relevant cardiac history or concerns:

Current Cardiac Evaluation:

Please indicate the date of the patient's most recent cardiac evaluation and provide any relevant findings or recommendations:

  • Date of last cardiac evaluation: ____________________________________
  • Results/findings: __________________________________________________
  • Recommendations for oral surgery clearance (if any):

Primary Care Physician/Cardiologist Information:

  • Name of Primary Care Physician/Cardiologist: ________________________
  • Medical Practice/Group: ____________________________________________
  • Address: _________________________________________________________
  • Phone Number: ___________________________________________________

Additional Notes or Instructions:

Please include any additional notes or instructions relevant to the cardiac clearance request:

Requesting Dentist/Oral Surgeon Information:

  • Name of Dentist/Oral Surgeon: ______________________________________
  • Dental Practice/Office: _____________________________________________
  • Address: _________________________________________________________
  • Phone Number: ___________________________________________________

Patient Consent:

I, the undersigned patient (or legal guardian), hereby authorize the release of medical information to the requesting dentist/oral surgeon for the purpose of obtaining cardiac clearance for the planned oral surgery procedure.

Patient/Legal Guardian Signature: _______________________ Date: _________

Physician Consent:

I, the undersigned primary care physician or cardiologist, confirm that I have reviewed the patient's cardiac history and recent cardiac evaluation. Based on my assessment, I provide cardiac clearance for the planned oral surgery procedure as described.

Physician Signature: ___________________________ Date: ______________