SOUND DENTAL CARE PCP ORDERS

Request for Primary Care Provider (PCP) Orders
Primary Care Provider:*

First NameLast Name
Regarding Patient:*

First NameLast Name
Name of Care Community (if applicable)
Fax Number at Care Community (if applicable)
Please enter a valid fax number.
The Individual, Resident, or his or her POA/Guardian has requested dental hygiene services. The treatment will involve initial evaluations, oral infection control through the removal of bacterial debris by scaling and root debridement, possible denture/partial cleaning, and the application of topical fluorides for caries prevention, as needed. The scaling and debridement are likely to cause gingival bleeding, transient bacteriemia and concern for persons who receive anticoagulants. Topical anesthetic and oral rinses may be used.

Appointments are scheduled for 45 to 60 minutes in length. Follow-up appointments will be scheduled as needed with the consent of the patient or the patient's POA/Guardian. The patient will be referred to their dentist of record for comprehensive dental services.
The Individual or Resident may receive dental hygiene services as needed.*
Premedication is required as annotated below:
PCP Comments
If dental hygiene services are authorized above and a premedication is required prior to dental services, please complete the prescription and comment portions below. If this section is left blank, the orders are indicating that the PCP is not prescribing a premedication for dental hygiene appointments.
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Request for Primary Care Provider (PCP) Orders