PREGNANCY

PREGNANCY

Patient: _______________

Date: ___/___/___

Our Patient has informed us that she is PREGNANT. 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 X-Rays & use a Lead Apron, & ONLY as necessary, for Emergencies & Dental Pain.

ANESTHETIC:

[ ] Xylocaine (Lidocaine) 2% w/ Epinephrine 1/100,000 No
[ ] Mepivacaine (Carbocaine) 3% (no vasoconstrictor) No
Nitrous Oxide is NOT used on our Pregnant Patients.
We do NOT use IV Sedation, nor General Anesthesia.

ANTIBIOTICS: Would you recommend:

[ ] Prophylactic Antibiotic Coverage
[ ] Amoxicillin         <> 2 gm           <> 3 gm
[ ] Erythromycin      <> 2 gm           <> 3 gm
[ ] ___________      <> _ gm           <> _ gm
We do NOT prescribe Tetracycline for Pregnant women.

No
No
No
No

ANALGESICS: If indicated, would you recommend:

[ ] Tylenol
[ ] Tylenol w/ Codeine #3

[ ] Aspirin
[ ] Vicodin

[ ] Ibuprofin
[ ] Synalgos DC

CLEANINGS / PROPHYLAXIS:

[ ] First

[ ] Second

[ ] Third

[ ] Trimester

We do NOT use Ultrasonic/Cavitron machines if patient is pregnant.

TIMING OF TREATMENT & RESTRICTIONS: