Patient Information
Patient Name:
First Name
Last Name
Date of Birth:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's Date:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Procedure Information
Planned Procedure:
Proposed Surgery Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Treating Oral Surgeon: Ryan Falke, DDS
Medical Clearance - Physician to Complete
Please evaluate the patient and provide recommendations regarding their ability to safely undergo the planned oral surgery procedure.
Rows
Yes
No
Does the patient have medical conditions that may affect their ability to undergo oral surgery?
Is the patient medically optimized for the proposed procedure?
Are any precautions or modifications recommended?
Are there any medications that should be held or adjusted before surgery?
Additional recommendations or concerns
Physician Information
Physician name:
First Name
Last Name
Practice name:
Phone:
Format: (000) 000-0000.
Fax:
Format: (000) 000-0000.
Physician Signature:
*
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