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Dental Clearance Form Template

Streamline Your Dental Clearance Process with Ease

Navigating the complexities of dental treatment clearance can be overwhelming. This Dental Clearance Form template is designed for dental practitioners and healthcare providers seeking to streamline patient documentation for dental procedures. With this template, you can efficiently gather essential patient information, ensure compliance with medical standards, and facilitate quicker treatment approvals, thereby enhancing your practice's workflow, reducing errors, and improving patient satisfaction. Give the live template a try to simplify your dental clearance process.

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Patient full name
Date of birth
Patient phone
Patient email
Patient ID / Medical Record Number (if applicable)
Preferred contact method
Phone call
Text message
Email
No preference
Treating dentist full name
Practice/clinic name
Clinic phone
Clinic email
Planned dental procedure
Routine exam/cleaning
Tooth extraction
Root canal treatment
Periodontal surgery
Dental implant placement
Dental restoration/filling
Other
Please Specify:
If other procedure, please specify
Proposed procedure date
Procedure urgency
Routine (no time constraints)
Soon (1-2 weeks)
Urgent (within 72 hours)
Anticipated anesthesia/sedation
Local anesthesia without epinephrine
Local anesthesia with epinephrine
Nitrous oxide
Oral sedation
IV sedation or general anesthesia
Unknown
Clearing provider full name
Practice name
Practice address
Provider phone
Provider fax
Provider email
License or NPI number
Date of medical evaluation
Specialty/role
Primary care
Cardiology
Hematology
Endocrinology
Oncology
Orthopedics
Anesthesiology
Other
Please Specify:
Significant medical conditions (select all that apply)
Please Specify:
Pregnancy status (if applicable)
Not pregnant
Pregnant
Possibly pregnant
Not applicable
Allergies (select all that apply)
Please Specify:
Allergy details or reactions
Current medications (include doses and frequency)
Currently on anticoagulant or antiplatelet therapy?
Yes
No
If on anticoagulant/antiplatelet therapy, list agents and dosing
Most recent INR value (if on warfarin)
INR test date
Most recent blood pressure
Most recent A1C or fasting glucose (if diabetic)
Antibiotic prophylaxis indicated per current guidelines?
Yes
No
ASA physical status
ASA I
ASA II
ASA III
ASA IV
ASA V
Unknown/Not assessed
Clearance decision for the planned dental treatment
Cleared without modifications
Cleared with modifications/precautions
Not cleared at this time
Insufficient information to determine clearance
Required modifications or precautions (select all that apply)
Adjust or hold anticoagulation per managing provider
Limit epinephrine dose
Monitor blood pressure before and during treatment
Antibiotic prophylaxis per guidelines
Avoid NSAIDs
Local anesthesia only; avoid sedation
Defer elective dental treatment
Other
Please Specify:
Details for modifications/precautions or other instructions
Local anesthesia with epinephrine acceptable?
Yes
No
If epinephrine acceptable, maximum recommended dose
If antibiotic prophylaxis is required, recommended agent, dose, and timing
Minimum platelet count or other lab thresholds (if applicable)
Additional recommendations or notes
Is antibiotic prophylaxis required?
Yes
No
I attest that the above assessment is accurate to the best of my knowledge
Yes
No
Signing provider name
Provider signature
Signature date
Return instructions or additional contact details
Preferred method to return this form
Fax
Secure email
Patient to deliver
Other
Please Specify:
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Patient phone","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a dental clearance form template for FormCreatorAI article

When to use this form

This form is helpful when a patient needs written clearance from a physician before extractions, implants, periodontal surgery, or deep cleanings. Use it for patients on anticoagulants, with cardiac issues, uncontrolled diabetes, pregnancy, recent joint replacement, or planned hospital surgery requiring dental sign-off. It helps you collect medical history, physician input, and treatment recommendations in one place, so you can schedule safely and avoid delays. Pair it with a recent clinical assessment using the Dental exam form and, if you must share history between offices, the Dental records release form. For insurance or hospital review, attach a concise summary using the Dental narrative submission form.

Must Ask Dental Clearance Questions

  1. Which medical conditions or recent surgeries do you have, such as heart disease, stroke, joint replacement, or pregnancy?

    This flags risks and whether you need physician guidance or antibiotics. It informs decisions to delay care, modify anesthesia, or choose a different approach.

  2. What medications, supplements, or blood thinners are you taking, including doses and prescriber?

    Drugs can raise bleeding risk or interact with anesthetics and antibiotics. Knowing the exact name, dose, and timing helps your dentist coordinate safe adjustments with your doctor.

  3. What are your most recent blood pressure, A1C, and INR (if on warfarin), and the test dates?

    Objective numbers show stability for procedures with bleeding or stress. High BP, poor glycemic control, or elevated INR may require postponement or a different plan.

  4. Do you have any allergies or past reactions to anesthesia, antibiotics, or latex?

    Clear allergy details prevent emergencies and guide safe material and medication choices. This supports accurate premedication and consent.

  5. What procedure is planned (e.g., extraction, implant, deep cleaning) and when is the deadline for medical sign-off?

    Physicians tailor recommendations to the specific procedure and urgency, which speeds approvals. You can also confirm benefits and timelines with the Dental insurance verification form.

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