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: ______________

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