Medical Clearance Form For Chemotherapy Patients

Medical Clearance Form For Chemotherapy Patients
NB: Only in emergency situations will we provide dental hygiene or other dental treatment. Elective invasive dental procedures will be deferred until after chemotherapy induced immunosuppression ceases. Specifically when: neutrophil count is > 1000/μl, the granulocyte count > 2000 μl and the platelet count > 50,000 or 75,000/μl. This status usually occurs about 17 days after chemotherapy.
PATIENT's name

First NameLast Name
Date form completed

MonthDayYear
Date
PATIENT's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This patient's next dental hygiene appointment at our office is on:

MonthDayYear
Date
Name of PHYSICIAN completing this form

First NameLast Name
Physician Specialty (GP, oncologist, etc,)
PHYSICIAN's phone number
Please enter a valid phone number.Format: (000) 000-0000.
PHYSICIAN's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHYSICIAN's email address
example@example.com
Date Of Patient's MOST RECENT Chemotherapy Treatment

MonthDayYear
Date
Today

MonthDayYear
Date
Number Of Days Since Most Recent Treatment
Was this the patient's final treatment
Is radiation therapy being planned?

Recent Bloodwork

Rows	Date of Bloodwork	Count
Neutrophil Count (should be > 1,000/μL)
Granulocyte Count (should be > 2,000/μL)
Platelet Count (should be > 50,000/μL)

NOTE: Our office requires that all patients who have undergone or who are undergoing chemotherapy have blood work conducted, reviewed and approved by their physician 24 hours prior to dental treatment to ensure their safety and wellbeing.
Is antibiotic prophylaxis required prior to the patient receiving a dental cleaning or treatment?
An antibiotic is usually prescribed if the white blood cell count is < 1000 - 2000/μl or if the neutrophil count < 500 - 1000/μl.
If you answered "Yes" that an antibiotic prophylaxis IS required, please provide medication and dosage details. Dr. Deskin can write the prescription, if you prefer.
Do you advise any alterations to the dental hygiene instrumentation?
If dental procedures are absolutely necessary and this patient is in a state of significant thrombocytopenia, can you arrange for platelet support therapy?
Please check one option
Limitations/Conditions under which this patient can undergo dental treatment and/or a dental cleaning:
My additional notes:
Physician's signature, certifying accuracy of information entered herein.
Should be Empty: