Medical Consult

MEDICAL CONSULT

Patient: _______________

Date: ___/___/___

Our patient has informed us that there are Medical Considerations that should be noted with respect to the dental treatment proposed.
Please comment on the following topics, and add any other recommendations you consider to be in our patient's best interest. You may write on this form, telephone or fax us.

TREATMENTS PROPOSED:

[ ] Cleaning / Scaling
[ ] Fillings
[ ] Perio/Gum Surgery

[ ] Root Canal
[ ] Crowns
[ ] ___________

[ ] Extractions
[ ] Implants
[ ] ___________

X-RAYS:

We take a Full set of X-rays every 3 years, and a simple Recall set every 6 months.
A lead apron is used. Emergencies & dental treatment are indications for X-rays.

ANESTHETIC:

[ ] Xylocaine (Lidocaine) 2% w/ Epinephrine 1/100,000
[ ] Mepivacaine (Carbocaine) 3%
[ ] Nitrous Oxide inhalation analgesia
We do not use IV Sedation, nor General Anesthesia.

No
No
No

ANTIBIOTICS: Would you recommend:

[ ] Prophylactic Antibiotic Coverage:
[ ] Amoxicillin         <> 2 gm           <> 3 gm
[ ] Erythromycin      <> 2 gm           <> 3 gm
[ ] ___________      <> _ gm          <> _ gm

No
No
No
No

ANALGESICS: If indicated, would you recommend:

[ ] Tylenol
[ ] Tylenol w/ Codeine #3

[ ] Aspirin
[ ] Vicodin

[ ] Ibuprofin
[ ] Synalgos DC

[ ] _________
[ ] _________

CLEANINGS / PROPHYLAXIS:

[ ] Ultrasonic / Cavitron machine use
[ ] Hand Scaling & Polish only

No
No

RESTRICTIONS / LIMITATIONS of TREATMENT:

[ ] Bleeding problems: ______________________________________________
[ ] Medicine Regime: ______________________________________________

Date: ___/___/___ Signature: _____________________________________