Medical Release - Tompkins

Tompkins Dental Health, PC
Tompkins Dental
2309 N Triphammer Rd
Ithaca NY 14850
607-257-8065
Fax 607-257-4782

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:

Tompkins Dental Health, PC