Medical Clearance Form For Chemotherapy Patients

The information that is requested on this questionnaire is essential to providing our patients with the highest standard of dental care. The protection and privacy of our patients' personal information is important to our office and we are committed to collecting, using and disclosing this information responsibly in accordance with our Privacy Policy.

To remain compliant with regulatory bodies, 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.

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*

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:

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*

Date

Today

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.