Medical Release

Elite Dental & Denture PC
13 Clinton Ave.
Cortland NY 13045
607-758-7700
Fax 607-758-7704

MEDICAL RELEASE
Date

MonthDayYear
Date
TO WHOM IT MAY CONCERN:
Patient Name
Requires:

ExtractionsFillingsCrown and BridgeRoot canalCleaning
They have stated in their medical history that they have:
Question(s) regarding the patient are as follows:
We would like to know if there are any necessary Precautions and Premedications?

Please respond in writing on doctors' letterhead.
Should be Empty:

Elite Dental & Denture PC