Referral For Physician’s Evaluation

Our dental patient,

___________________________________________

(date of birth: _____________________)

has informed us that the following condition is present:

  ______________________________________

The patient will be having dental procedures done that may create a transient septicemia.

Please evaluate the patient's records to confirm the need for prophylactic antibiotic premedication before high risk dental procedures, and return the next page with your recommendation.  Thank you!

Sincerely,

John Doe, D.D.S.

Please return to:

John Doe, D.D.S.
Office address
City, State ZIP
Fax (xxx) xxx-xxxx

Dr. Doe:

I have evaluated the records of our mutual patient ( _____________________________ ), and advise the following:

No prophylactic antibiotic premedication is needed.

2 grams  Amoxicillin orally one hour before treatment as per American Heart Association and the American Academy of Orthopaedic Surgeons.

600mg  Clindamycin orally one hour before treatment as per American Heart Association and the American Academy of Orthopaedic Surgeons.

2g  Cephalexin or Cefadroxil orally one hour before treatment as per American Heart Association and the American Academy of Orthopaedic Surgeons.

500mg Azithromycin or Clarithromycin orally one hour before treatment as per American Heart Association.

Other:     ________________________________________________

                   __________________________________________________

                   __________________________________________________

_______________________________________
Physician

_______________________
Date