Dear Healthcare Partner,
Our mutual patient requires restorative dental treatment. Occasionally we receive incomplete or inaccurate
medical histories from caregivers. As a precaution we are asking that you complete this form and fax it back to our
office within 48 hours of the treatment date. This will allow us to verify or amend current information as well as
deliver safe and effective care. We sincerely thank you for your cooperation.
Patient: _____________________________
Today’s Date: ____________
Treatment Date: _____________
PROPOSED TREATMENT
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
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Local Anesthesia (2% Lidocaine w/1:100:000 epinephrine)
Nitrous Oxide
Dental Restorations (fillings, crowns, sealants)
Dental Extractions
Oral Sedation (Midazolam and Hydroxyzine combination)
IV Sedation (administered by an Anesthesiologist and monitored by a Registered Nurse)
General Anesthesia in an ambulatory surgery center
MEDICATIONS
Yes  No 
Please list any medications the patient is taking per your records
Does the patient require antibiotic prophylaxis before treatment?
RECOMMENDATIONS
Please check the box that applies to this patient


I am not aware of any contraindications to receiving stated dental treatment.
The patient can receive the above dental treatment, but I urge caution for the following reasons:

I recommend the patient not receive the above dental treatment for the following reasons:
PRECAUTIONS
Please list any special precautions necessary before, during or after treatment
COMMENTS
Yes  No 
Is the patient medically stable and able to undergo the above procedures?
Physician’s Signature: ________________________________________________________
Date: __________
1690 RIMROCK ROAD STE. C BILLINGS, MT 59102 | PH: (406) 248-3303 | FAX: (406) 248-3939