MEDICAL CLEARANCE & COORDINATION FORM

RALPH W ALMAN JR DDS PA ✧ Oral Surgery & Implants

11300 Rockville Pike #1011 Rockville, MD 20852

E-mail: patient@secure.dentalsurgerymd.com ▫︎ 301.881.8803 ▫︎ FAX 240.474.0409

PHYSICIAN CLEARANCE/COORDINATION FOR ORAL SURGERY PROCEDURE(S)

Date:

Date

Patient Name:

First NameLast Name

DOB:

Date of Birth

Sex:

MaleFemale

Patient Contact Information:

Primary Contact #:

Primary Contact E-Mail:

Primary Contact Name if Not Patient:Relationship:

Dr. Alman is requesting medical clearance/coordination. To discuss this case directly with Dr. Alman, please call Dr. Alman at 301.717.4315 (4:30pm-8pm M-F). Do not leave messages or text to this private number.

Website: dentalsurgerymd.com (The forms on this website are HIPAA compliant)

Email: patient@secure.dentalsurgerymd.com

Dr. Alman's Notes:

Procedure Planned & Clinical Notes.

Clearance Form Completed By:

Patient After Contacting the Physician(s)Family Member - After Contacting the Physician(s)Physician or Physician's Staff on behalf of the Physician

Physician Requested for Medical Clearance/Coordination:

Physician Name

Specialty

Telephone #Fax #

E-Mail

OVERALL ASSESSMENT: I have reviewed the relavant data and my assessment is:

Patient is able to proceed with an In-Office Procedure.

YESYES - with the following conditions/modifications.NO - This patient is NOT able to proceed with an in-office procedure.

Contraindicated reason(s):

Please provide details including any considerations or other medical management.

Contraindicated reason(s):

Please provide details including any considerations or other medical management.

In-Office Procedure Conditions/Modifications:

Please provide details including any considerations or other medical management.

In-Office Procedure Conditions/Modifications:

Please provide details including any considerations or other medical management.

In-Office Sedation:

YES - This patient is able to proceed with In-Office Sedation.YES - This patient is able to proceed with In-Office Sedation with the following considerations/modifications.NO - This patient is NOT a candidate for In-Office Sedation.

Considerations/modifications for in-office Sedation:

Please provide details including any considerations or other medical management.

Considerations/Modifications for In-Office Sedation:

Please provide details including any considerations or other medical management.

Is Local anesthetic with EPINEPHRINE allowed?

YESNO

Is Local anesthetic with EPINEPHRINE allowed?

YESNO

Are there ANY restrictions for anesthetics?

YESNO

Are there ANY restrictions for anesthetics?

YESNO

Restrictions for Anesthetics:

Supplemental Work-Up Required Before Proceeding:

No supplemental work-up required.Proceed following additional evaluation with:

Supplemental Work-Up Requested Before Procedure(s):

Does this patient require Antibiotic Prophylaxis?

YESNO

Does this patient require Antibiotic Prophylaxis?

YESNO

Reason & type of antibiotic prophylaxis recommended/allowed.

Please provide details including any considerations or other medical management.

Reason & type of antibiotic prophylaxis recommended/allowed.

Please provide details including any considerations or other medical management.

Do you treat this patient for Diabetes?

YESNO

Do you treat this patient for Diabetes?

YESNO

Diabetes Instructions.

Please provide details including any considerations or other medical management.

Diabetes Instructions.

Please provide details including any considerations or other medical management.

NSAIDs - Are NSAIDs allowed? Our office uses Ketoraloc (Tordol) in wisdom teeth procedures (elective) & often prescribes Ibuprofen for the basice pain medication.

YESNO

NSAIDs - Are NSAIDs allowed? Our office uses Ketoraloc (Tordol) in wisdom teeth procedures (elective) & often prescribes Ibuprofen for the basice pain medication.

YESNO

NSAIDs including aspirin, baby aspirin, and aspirin containing products Instructions.

Please elaborate on when to stop and restart. Please provide details including any considerations or other medical management.

NSAID Details: NSAIDs including aspirin, baby aspirin, and aspirin containing products Instructions.

Please elaborate on when to stop and restart. Please provide details including any considerations or other medical management.

Have you prescribed or are you currently prescribing any Anticoagulants / Antiplatelet drugs / & Blood Thinners?

YES - No Interruption or modification of medication is required.YES - Patient is UNABLE to stop or have medication dosage altered.YES - Proceed with the Following Management Plan.NO

Medication Management Plan:

Additional Notes:

Please describe & elaborate.

Have you prescribed medication(s) for Bone Density (including Osteoporosis) - Now or in the past?

YESNO

Have you prescribed medication(s) for Bone Density (including Osteoporosis) - Now or in the past?

YESNO

Bone Density:

Please provide details including any considerations or other medical management.

Bone Density Management:

Please provide details including any considerations or other medical management.

Medical Conditions & Medications Not Listed Above:

YESNO

Medical Conditions & Medications Not Listed Above:

YESNO

Other Medical Conditions & Medications Not Listed Above:

Cancer, Chemo, Dialysis, Disorders, Conditions, Medications Etc. - Please describe & elaborate.

Additional Information:

If there is any additional information please provide it here.

MEDICAL COORESPONDANCE:

Please add any lab results, hospital reports, or other files as needed.

Physician's Signature

Please sign here.

Signature

Please sign here.