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    Med Consult

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    jenea t
    This document is a medical consultation request form used by dentists to request information from physicians about patients' medical conditions prior to dental treatment. The form requests information about a patient's need for antibiotic prophylaxis, cardiovascular condition, bleeding risk, and infectious disease history. It also provides options for the physician's response regarding treatment clearance and any special precautions.

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    Download as PDF, TXT or read online from Scribd

    Med Consult

    Uploaded by

    jenea t
    34 views1 page
    This document is a medical consultation request form used by dentists to request information from physicians about patients' medical conditions prior to dental treatment. The form requests information about a patient's need for antibiotic prophylaxis, cardiovascular condition, bleeding risk, and infectious disease history. It also provides options for the physician's response regarding treatment clearance and any special precautions.

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    This document is a medical consultation request form used by dentists to request information from physicians about patients' medical conditions prior to dental treatment. The form requests information about a patient's need for antibiotic prophylaxis, cardiovascular condition, bleeding risk, and infectious disease history. It also provides options for the physician's response regarding treatment clearance and any special precautions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    34 views1 page

    Med Consult

    Uploaded by

    jenea t
    This document is a medical consultation request form used by dentists to request information from physicians about patients' medical conditions prior to dental treatment. The form requests information about a patient's need for antibiotic prophylaxis, cardiovascular condition, bleeding risk, and infectious disease history. It also provides options for the physician's response regarding treatment clearance and any special precautions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    MetLife MEDICAL CONSULTATION REQUEST Pacific Dental School

    To: Dr.__________________________________ Please complete the form below and return it to

    _________________________________ Dr. ___________________________________


    _________________________________ ______________________________________
    RE: __________________________________ ______________________________________
    __________________________________
    Date of Birth Phone#________________________________

    Fax#__________________________________
    Our patient has presented with the following medical problem(s):________________________________
    ____________________________________________________________________________________
    ____________________________________________________________________________________
    The following treatment is scheduled in our clinic:_____________________________________________
    ____________________________________________________________________________________
    Most patients experience the following with the above planned procedures:
    bleeding: minimal (<50ml) significant (>50ml)
    stress and anxiety: low medium high

    _________________________________ _____________________
    Dentist’s signature Date

    PHYSICIAN’S RESPONSE
    Please provide any information regarding the above patient’s need for antibiotic prophylaxis, current cardiovascular condition,
    coagulation ability, and the history and status of infectious diseases. Ordinarily, local anesthesia is obtained with 2% Lidocaine,
    1:100,000 epinephrine. For some surgical procedures, the epinephrine concentration may be increased to 1:50,000 for
    hemostasis. The epinephrine dose NEVER exceeds 0.2 mg total.

    CHECK ALL THAT APPLY


    OK to PROCEED with dental treatment; NO special precautions and NO prophylactic antibiotics
    are needed .
    Antibiotic prophylaxis IS required for dental treatment according to the current American Heart Association
    and/or American Academy of Orthopedic Surgeons guidelines.
    Other precautions are required: (please list)________________________________________________
    ______________________________________________________________________________________
    DO NOT proceed with treatment. (Please give reason)_______________________________________
    ______________________________________________________________________________________
    Treatment may proceed on (Date)_________________
    Patient has an infectious disease:
    AIDS (please provide current lab results) Hepatitis, type ______, (acute/carrier)
    TB (PPD+/active) Other (explain)___________________
    Requested relevant medical and/or laboratory information is attached.

    ____________________________________ _____________________
    Physician Signature Date

    PATIENT CONSENT
    I agree to the release of my medical information to the above named dentist office.

    ___________________________________ ___________________
    Patient Signature Date

    This Medical Consultation form is created and maintained by the University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California.
    Support for the translation and dissemination of the Health Histories comes from MetLife Dental.

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