Dental Clearance Form: Medical Consultation Template and Checklist

A dental clearance form usually asks a medical clinician for information that will help a dentist plan treatment. The useful output is a response to specific questions about a named procedure, relevant medical conditions and medicines, with clear recommendations and any unresolved issues. The dentist uses that information to make an individualized dental treatment decision.

This guide covers medical consultation before adult outpatient dental care. A hospital or surgeon asking a dentist to assess oral health before an operation is requesting a different kind of dental clearance. Identify the direction of the request before choosing a form.

Download the three-page printable form or copy the request, response and internal review sections. Sources checked October 29, 2026.

Copyable dental clearance form

The outgoing request, medical response and internal review have different authors and destinations. Copy the section you need. Keep clinical answers tied to their source and date, and distinguish “unknown,” “not assessed” and confirmed negative findings.

Part 1: the dentist’s request

Describe the procedure precisely enough for the recipient to understand what is being proposed. “Dental work” could mean a routine restoration or an extensive surgical procedure. Include the site and extent, planned date, reason for urgency, and anesthetic or sedation plan. If details are undecided, say so and identify who will provide them.

The exposure-history fields cover past as well as current treatment. Include discontinued antiresorptive or antiangiogenic medicines and prior head-and-neck radiation, with the details available from the patient or dated records. Mark unknown details and identify the clinician or record needed to confirm them; a current medication list alone may miss earlier treatment. The AAFP review recommends communicating these histories and their treatment details to the dentist.

Part 2: the medical response

The responding clinician should identify the request being answered and the information reviewed. Separate an answer that is complete from one awaiting another record or assessment. Where a medication instruction changes, preserve the exact instruction, prescriber and communication status. Record proposed changes, authorized prescriptions and delivered patient instructions as separate steps.

For a narrative reply, use the medical clinician’s response-letter template. It answers the dentist’s request in letter form.

The printable PDF places the request on page one, response on page two and internal dental review on page three. It is a handwriting worksheet; copy the text into an approved document for typed completion. Repeat the patient identifier on each page and link dated continuation entries when more space is needed.

Ask a question the medical clinician can answer

“Please clear for treatment” leaves the recipient to infer both the procedure and the concern. A better request names the uncertainty: “Please confirm the current anticoagulant and whether your recommendation requires a change for the procedure described.” A second question might ask whether a particular cardiac history creates an antibiotic-prophylaxis indication. Number the questions so the reply can be checked against them.

The American Family Physician review, published in November 2021, recommends describing relevant conditions, treatment plans and current management, alongside medicines and allergies. It also identifies histories such as antiresorptive treatment and head-and-neck radiation that may matter to dental planning. Its recommendations include expert-consensus evidence.

Ontario: consultation and professional responsibility. In its March 11, 2026 Health Care Collaboration statement, RCDSO advises against requesting general medical clearance. It recommends relevant medical information and a specific risk assessment, supported by details of the proposed procedure, anesthesia and risks. The dentist retains responsibility for the dental treatment decision. The Ontario Medical Association’s guidance on requests from dentists likewise distinguishes sharing relevant history and answering medical-management questions from authorizing dental care. A physician may provide the relevant history instead of completing a particular form. Check the reply for the information needed to answer the clinical questions, rather than treating a missing signature on this worksheet as a missing consultation. Both sources were checked October 29, 2026.

Use an intake history to assemble facts, then decide what bears on the question. The medical history form guide helps distinguish a patient’s account, a previous chart entry and a verified update.

Three details make the request easier to act on:

1. A question with consequences: explain what decision depends on the answer, rather than requesting a generic signature.
2. A dated evidence set: identify the result, medication list or prior letter attached, including discrepancies that still need resolution.
3. A response route and checkpoint: name the recipient and who follows up if an answer has not arrived by the agreed time. Urgent clinical concerns use the appropriate direct clinical pathway, not a routine administrative queue.

Clinical questions that change the consultation

U.S. dental guidance, checked October 29, 2026. Frame each consultation around the patient’s history, the planned procedure and the question the responsible clinician needs to answer.

Anticoagulants and antiplatelet medicines

The ADA’s anticoagulant guidance says most patients do not need therapy altered before dental intervention. It distinguishes stronger evidence for older medicines from more limited evidence for direct-acting oral anticoagulants. For higher bleeding risk, suggested changes should be coordinated with the patient’s physician.

The documentation question is therefore broader than “stop blood thinner?” Capture the medicine, dose, indication, actual reported use and relevant dated results. Ask for a procedure-specific plan. Leave interruption, dose timing and restart instructions blank until an authorized clinician supplies them. A historical prescription is not proof that the person still takes it.

Antibiotic prophylaxis

The ADA’s current prophylaxis page distinguishes prosthetic joints from the relatively small group of cardiac conditions for which prophylaxis may be appropriate before certain procedures. A joint implant alone generally does not justify preventive antibiotics; a history of complications may require consultation with the patient and orthopedic surgeon. Cardiac eligibility and the dental procedure both matter.

Ask the respondent to identify the indication and rationale, not merely tick “premedicate.” If a prescription is needed, the record should identify the prescribing clinician, regimen, timing and allergy review. An antibiotic for an existing infection and prophylaxis before a procedure answer different questions and should have separate entries.

Blood pressure and other medical changes

The ADA hypertension resource discusses repeat measurements, symptoms, elective versus urgent dental care, and the limits of evidence for a single postponement threshold. It also notes that possible hypertensive-emergency symptoms may require immediate medical evaluation.

Preserve actual readings, units, measurement times, repeat values and reported symptoms. Ask the medical clinician about the current status and the dental question being considered. Keep new observations distinct from older “controlled” labels, and route urgent concerns through immediate clinical assessment. Describe fasting or sedation plans when they affect the question, and request an assessment of that specific scope.

Ontario: resolving different recommendations

The Royal College of Dental Surgeons of Ontario’s prophylaxis guidance supports discussing the evidence and the reason for an inconsistent recommendation with the patient and relevant clinician. It emphasizes that each provider remains responsible for their treatment decisions. Label the jurisdiction and guidance used, document the rationale discussed, and preserve the dentist’s final decision rather than overwriting one recommendation with another.

DT-01: a completed consultation and review

Fictional example. Follow the request, medication reconciliation, medical response and dentist’s decision through the record.

Source facts before completing the form

Alex is an adult booked for a single simple tooth extraction under local anesthesia, without sedation, on November 5. At the October 29 dental visit, Alex reports taking apixaban 5 mg twice daily for atrial fibrillation. A 2023 letter still lists warfarin. Alex also reports an uncomplicated knee replacement in 2019 and asks whether antibiotics are needed because an older dental form has a “premedication” box.

The dentist requests confirmation of the active anticoagulant and a plan for the stated extraction, plus clarification of any prophylaxis indication. Alex agrees to sharing the relevant records with the primary-care practice. The packet contains the current medication account and the dated historical letter; neither is silently discarded. The practice requests a response by November 2 and assigns the dental coordinator to track it.

On October 30, the fictional physician reviews the medication record, a renal result dated October 21 and the available cardiac and orthopedic history. The physician confirms the current apixaban regimen and that warfarin was discontinued in 2023. For the described procedure, the supplied recommendation is no anticoagulant change, with the dentist responsible for local bleeding-control planning. The physician identifies no prophylaxis indication in the reviewed history and explains that the knee replacement alone is not an indication. The response applies to the stated procedure and current information; changed medicines, health status or procedure scope require another review.

At 10:00 on November 2, the dental practice receives the response. At 11:20, the dentist reviews both numbered answers, reconciles the historical medication entry, and records a plan to proceed with the described extraction and local bleeding-control measures. At 11:40, the coordinator communicates the dentist-approved instructions to Alex through the agreed direct-call route. Alex explains back that no self-directed medication interruption is planned. The appointment is confirmed separately. The extraction itself has not occurred.

Completed record mapped to the form

The older warfarin letter remains part of the record with its date and corrected status. The current medication field, consultation response and patient instructions now agree. This is more informative than deleting the old letter or adding an undated “clearance received” label.

Practice: when a signed response is still incomplete

Consider this alternate draft response to the same request: “Medically cleared. Stop anticoagulant before treatment. Antibiotics as usual.” It is signed, but gives no current drug, dose timing, rationale, prescribing responsibility or procedure boundary. The coordinator changes the booking status to “ready.”

Show the request-to-response check

• Question 1 is unanswered: the active medication and the old warfarin entry have not been reconciled. “Stop anticoagulant” is not an executable, authorized plan with timing and responsibility.
• Question 2 is unanswered: “as usual” identifies neither an indication nor a prescription. A previous checkbox does not supply either.
• The scope is absent: the reply does not identify the extraction or anesthetic plan it addresses.
• The status is too strong: the practice has received a document, but the dentist has not accepted its answers or made the dental decision.
• The next action needs an owner: return the specific missing questions to the responding practice, assign the coordinator a follow-up checkpoint, and route the reply to the dentist. Record the actual scheduling decision rather than assuming either approval or cancellation.

Use this comparison to check each answer against the original request. The referral-letter guide also distinguishes sending a request from establishing that the next person has acted on it.

When the procedure or instructions change

Suppose the plan changes after DT-01 from one simple extraction under local anesthesia to several surgical extractions with sedation. The previous response still exists, but its stated scope no longer matches. The dental team should describe the revised procedure, identify which earlier answers need reconsideration, and record who will obtain the additional assessment. Do not change the date on the old response to make it appear current.

A medication discrepancy creates a similar problem. If a patient reports a new prescription on the day of treatment, attribute the new account and reconcile it through the responsible clinical team. “The form is signed” does not resolve a conflict between the form and current information. Preserve the original response, subsequent clarification, author and times, including any change to patient instructions or scheduling.

When an instruction is communicated by telephone, record who supplied it, the exact content, the procedure it addresses and any confirmation required by local policy. The collateral-information guide explains why a report from someone else must keep its source. The clinical note examples illustrate dated corrections that preserve the earlier account.

Internal dental review and follow-up

Assign administrative tracking and clinical decisions separately. The coordinator can verify receipt, chase a missing attachment and place a response in the dentist’s queue. The dentist evaluates whether the answers resolve the question and decides whether to proceed, modify, defer or seek more information. A completed administrative task should not automatically mark the clinical review complete.

For an unanswered request, record the next contact attempt, responsible person, agreed checkpoint and backup. If the planned treatment date approaches before the question is resolved, escalate to the dentist for a documented decision and patient communication. Set follow-up and recheck timing according to the clinical circumstances and the services involved.

Sending and record-handling checklist

Verify the intended recipient and return channel before sending. Select the information relevant to the consultation and document the information-sharing basis under the applicable rules. Keep the internal tracking record separate from the outward-facing request. An attachment list should identify versions and dates so a missing page is detectable.

For Ontario practices, use the RCDSO medical-history resource alongside the practice’s recordkeeping and consent processes.

Store the response where the treating dental team can retrieve it, associate it with the correct patient and request, and preserve subsequent amendments. Verify that relevant medication fields and open tasks match the narrative. The PHI guide discusses why identifiable information in an attachment or message needs attention alongside the main chart.

Quality checklist before the appointment

Use this final comparison across the request, medical reply, dental note and instructions:

1. The patient identifiers agree on every page and attachment.
2. The response names the procedure and request version it addresses.
3. Every numbered question has an answer or an assigned next action.
4. Current information is distinguished from historical and patient-reported information.
5. Medication instructions match the current authorized plan; no hold or restart was inferred.
6. Any prophylaxis decision has a rationale and, when prescribed, a named prescriber and complete instructions.
7. The dentist’s review and individualized treatment decision are recorded separately from receipt.
8. The patient communication records what was actually discussed, not what someone intended to send.
9. Booking, treatment and follow-up statuses reflect what has actually happened.
10. Changes in health, medicines or procedure scope prompt a documented recheck of the applicable advice.

A useful consultation form makes these decisions inspectable. It supports coordination while keeping the clinical judgment, its scope and the remaining work visible.