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Free printable form

Free dental clearance form for surgery or treatment

A dental clearance (a dental evaluation before surgery or treatment) is a short note from a dentist saying your mouth is ready, or listing what has to be done first. Print this free form, take it to your dentist, and have the dentist send it back to your care team.

For hospital and clinic teams

What to bring to the dentist

  • This form, with your care team's name and fax or email filled in at the top.
  • Your care team's date window or deadline, if they gave you one.
  • A list of the medicines you take.

How long does a dental clearance take?

The visit is usually one exam, often with X-rays. If the dentist finds something to treat first, it takes as long as that treatment. Some care teams want X-rays from the last few months, and some ask the dentist to send the form back by a set date. Ask your care team for their deadline and book the dentist as early as you can.

How much does it cost?

It depends on your dentist and your coverage. Ask the dental office when you book, and bring every insurance card you have, dental and medical.

Do I need one if I have no natural teeth?

Some care teams do not ask for one if you have no natural teeth. Ask your care team; their rule is the one that counts.

Your care team gave you their own form?

Use theirs. This form is for when you were not given one, or the one you have is missing pieces.

Dental clearance formFree from ireferral.org

1. Care team (filled in by the care team or the patient)

Care team or clinic
Contact person
Return by fax
or email
Please return by (date)
Phone

2. Patient

Name
Date of birth

3. Dentist

Date of exam
X-rays taken on
☐ No active infection or urgent problem found
☐ Treatment needed first:
Expected to be finished by
 
OK to proceed from a dental standpoint: ☐ Yes   ☐ Not yet
Notes for the care team
Dentist name
License number
Office phone
Signature and date

Send this page back to the care team at the fax or email in section 1. Keep a copy for the patient's chart.

Hospital and clinic teams: see when it arrives

Start a tracked referral with a reference code instead of a name, and you see when the dental office opened it and when it answered. It is free.

Start a referral

Questions staff ask: what happens after the order is placed. Patients: dental clearance before knee or hip replacement. Dental offices: medical clearance form for dental treatment.

The tracked referral carries no patient name, date of birth, diagnosis or notes. The paper form above stays between the patient, the dentist and the care team; nothing on it is sent to us.

General information, not medical advice. Your care team's instructions come first.