Last updated October 29, 2026.
How to use this form
- Fill in section 1 (dental office) and section 2 (patient) and the planned treatment in section 3.
- Send it to the physician by fax, or hand it to the patient to take.
- The physician answers section 4, signs and sends it back to the number in section 1.
- Keep the returned form in the patient's chart.
What to put in the questions
Ask only what changes the dental plan: conditions being treated, medicines that affect bleeding or healing, and anything the physician wants done differently, such as timing or precautions. A short, specific question gets a faster answer than a blank page.
Your physician gave you a form?
Use theirs. This form is for when none was given, or the one you have is missing pieces.
What is a medical clearance for dental treatment?
It is a note from a patient's physician answering a dentist's questions before dental work: the conditions being treated, the medicines, and whether anything should change for the visit.
Who fills it out?
The dental office fills in the top and sends it to the physician. The physician answers, signs and sends it back to the dental office.
Is a clearance always needed before dental work?
No. The dentist decides when to ask, based on the patient's history and the planned treatment. The physician's judgment is the one that counts on the medical questions.
The other direction
If the request starts at a hospital or clinic and asks the dentist for a report, see the dental clearance form.