Medical Clearance Request for Oral Surgery

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Clinic Name
Clinic Address
Clinic Phone Number
Clinic Email

Medical Clearance Request 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 medical clearance:

Medical History:

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

  • Previous surgeries or hospitalizations:
  • Allergies (medications, latex, food, etc.):
  • Current medications (prescription, over-the-counter, supplements):
  • Chronic medical conditions (diabetes, hypertension, heart disease, etc.):
  • History of bleeding disorders or clotting abnormalities:
  • Any other relevant medical history or concerns:

Primary Care Physician Information:

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

Additional Notes or Instructions:

Please include any additional notes or instructions relevant to the medical 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 medical clearance for the planned oral surgery procedure.

Patient/Legal Guardian Signature: _______________________ Date: _________

Physician Consent:

I, the undersigned primary care physician, confirm that I have reviewed the patient's medical history and provide medical clearance for the planned oral surgery procedure as described.

Physician Signature: ___________________________ Date: ______________