Dental Medical Clearance Form

Learn how a Dental Medical Clearance Form works. Download a free PDF template and sample for your practice.

By Ericka Pingol on May 15, 2024.

Fact Checked by Nate Lacson.

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What is a Dental Medical Clearance Form?

A Dental Medical Clearance Form is a document requested by dental professionals prior to performing certain dental procedures that could potentially impact a patient's overall health, especially if they have underlying conditions like coronary artery disease.

This essential form is part of the protocol to ensure safe dental care, indicating that the patient has undergone a thorough assessment and has received clearance from their medical provider for the proposed dental treatment. It's a precaution that underscores the importance of medical clearances in the synergy between medical and dental health.

By using a dental clearance form template, dental practitioners can streamline the process, ensuring that all relevant health information is recorded accurately. Once completed and reviewed by the necessary medical professionals, the medical clearance form allows the dental team to proceed confidently, understanding the full scope of the patient's health and ensuring patient safety.

Printable Dental Medical Clearance Form

Download this Dental Medical Clearance Form for dental practitioners to streamline the process, ensuring that all relevant health information is recorded accurately.

What are the parts of a Dental Medical Clearance Form?

Generally, a Dental Medical Clearance Form or medical and dental clearance template includes the following details:

  • Patient information: This section captures the patient's personal details, including their name, date of birth, and contact information.
  • Emergency contact: In case of any emergency, the form requests information on who to contact and their relationship to the patient.
  • Medical history: This section delves into the patient's medical background, including past and current illnesses, allergies, surgeries, medications, and lifestyle habits.
  • Dental treatment consent: The patient is required to sign a consent form indicating their understanding and agreement to the proposed dental treatment.
  • Dental provider's information: This section records the dental practitioner's details, such as their name, license number, and contact information.
  • Dentist's notes: The dentist notes section is used to document any specific concerns or findings related to the patient's dental health.

How does our Dental Medical Clearance Form work?

Our printable Dental Medical Clearance Form makes it easy for you and your patients to complete the necessary documentation. Follow the steps below to use the template

Step 1: Access the template

Download the free Dental Medical Clearance Form using the link on this page. You may also get it from our resources library or the Carepatron app.

Step 2: Give your patient a copy

As the patient's medical provider, it is your job to explain the purpose and importance of filling out the form. Provide them with a blank copy to fill out at their convenience. Highlight the significance of completing the form before starting any dental procedure.

Step 3: Have the patient complete the form

Advise your patient to provide accurate information on their personal details, emergency contact, medical treatment, and other relevant information. Remind them to carefully read through and understand the dental treatment consent section before signing.

Step 4: Review and sign

Once the patient has completed the form, review it for any missing or incorrect information. Make sure that all fields are properly filled before signing the document. As a medical provider, your signature indicates that you have thoroughly reviewed the form and agree to provide dental treatment.

Step 5: Keep a copy for your records

Retain a copy of the signed Dental Medical Clearance Form in the patient's medical file for future reference. This proves that informed consent was given and helps track the patient's dental health history.

Dental Medical Clearance Form example

The team at Carepatron has made a sample completed Dental Medical Clearance Form available for reference. This example provides an idea of how the form should be filled out and what information is required. However, note that each patient's medical history and treatment plan may differ, so it is important to have each patient fill out their own unique form.

Download our free Dental Medical Clearance Form template example

Dental Medical Clearance Form example

What are the benefits of a Dental Medical Clearance Form?

Our free Dental Medical Clearance Form template can provide numerous benefits to both your patient and your dental practice:

Ensures patient safety

By having patients fill out a Dental Medical Clearance Form before commencing dental treatment, you can identify any pre-existing medical conditions or allergies that may impact the procedure. This allows you to take necessary precautions and ensure your patient's safety during their visit.

Details informed consent

Having patients sign the Dental Medical Clearance Form also proves informed consent. It shows that they have understood the potential risks and benefits of the procedure and have agreed to move forward with it.

Fully digital and easy to use

Our template is designed to be fully digital and can be easily filled out by patients on any device. This saves time for both the patient and your dental practice, eliminating the need for paper forms and manual data entry.

Encourages transparency and communication

Providing patients with a Dental Medical Clearance Form encourages them to communicate openly about their medical history and any concerns they may have. This promotes transparency between the patient and the dental team, allowing for better treatment planning.

Is medical clearance always advised before dental procedures?
Is medical clearance always advised before dental procedures?

Commonly asked questions

Is medical clearance always advised before dental procedures?

Medical clearance is usually advised before certain dental procedures, especially if you have underlying health conditions or are taking medications that could affect your dental care. It's a precautionary step to ensure your safety and optimal treatment outcomes.

Why should patients seek medical clearance before a procedure?

Patients should seek medical clearance before a procedure to inform their dental team of any potential risks or contraindications that could impact the treatment. This allows for proper preparation and precautions to be taken, ensuring the patient's safety during their visit.

What information should be included in a Dental Medical Clearance Form?

A completed medical clearance form should include relevant medical history, current medications, allergies, and any current or past medical conditions. It should also include emergency contact information and any relevant insurance details.

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