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.
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*

YesNoUncertain
Is radiation therapy being planned?*

YesNoUncertain

Recent Bloodwork*

	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?*

YesNo
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?*

YesNo
If dental procedures are absolutely necessary and this patient is in a state of significant thrombocytopenia, can you arrange for platelet support therapy?*

YesNo
Please check one option*

I, this patient's physician, DO provide my CONSENT for this patient to have dental work and/or dental cleanings.I, this patient's physician, DO NOT provide my CONSENT for this patient to have dental work and/or dental cleanings.I, this patient's physician, DO provide my CONSENT for this patient to have dental work and/or dental cleanings but ONLY with the LIMITATIONS/CONDITIONS I SPECIFY BELOW.
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.

Clear
Should be Empty: