DENTAL CLEARANCE LETTER

[Practice name]
[Address]
[Phone and fax]

Date: [Date you write the letter]
To: [Dentist or oral surgeon, practice, and phone or fax]

Re: [Patient's full name]
Date of birth: [Date]

Thank you for your request of [date] about [patient name], who is planning [the dental procedure, e.g. extraction of 2 teeth] on [date, if known]. [Patient name] agreed that I could share the information below with you.

RELEVANT CONDITIONS
[Only what bears on dental care, with dates: e.g. atrial fibrillation, a coronary stent and when it was placed, a heart valve replacement and its type, a joint replacement and when]

MEDICINES AND ALLERGIES
Medicines: [Each relevant medicine, its dose, and why the patient takes it]
Drug allergies: [Each drug and the reaction, or none known]

BLOOD THINNERS
Medicine: [Name, dose, and reason, or none]
Latest INR, for warfarin: [Result and date, or not applicable]
Other bleeding risks: [Kidney or liver disease, low platelets, a second blood thinner, or none known]
Recommendation: [Continue without change; or the exact change, by dose and day, e.g. take the morning dose after the procedure]
Please do not stop [medicine] without speaking to me first. [For dual antiplatelet therapy after a stent: neither drug should be stopped without the cardiologist]

ANTIBIOTIC PROPHYLAXIS
Highest-risk heart condition for endocarditis: [None, or which one]
Joint replacement or other implant: [None, or which one and when]
Recommendation: [Not indicated, and why; or indicated, with the regimen, the timing, and who will prescribe it]

OTHER CAUTIONS
[Antiresorptive medicines such as a bisphosphonate or denosumab, with the route and how long; diabetes control with the latest A1C; a recent heart attack, stroke, or stent, with the date; or none]

The dental treatment plan, and how to carry it out, is your decision. Please call me if the procedure changes or you have questions.

[Your name, credentials]
[License or registration number]
[Signature]
Direct line for your office: [Phone or fax]