Order Number Patient's Name * Patient's DOB * Today's Date * I examined your patient on the above date and recommend the following dental treatment: Before proceeding we want to ensure the patient can be treated safely. Your patient indicated that he/she has the following medical conditions: In your opinion are there any contraindications to performing the needed dental treatment? Do you recommend pre-medication for this patient and if so, what type? Other recommendations or instructions: Physician's Name * Physician's Phone # * Physician's Fax # Physician's Office Name * Physician's Email * Physician's Signature Parent's Name * I hereby authorize my Physician to release any pertinent facts regarding my child's medical history to Dr. Brian Hatch of Mountain View Pediatric Dentistry. Relationship to Child * Parent's Signature Sincerely, Dr. Brian Hatch, DMD Board Certified Pediatric Dentist Mountain View Pediatric Dentistry 1904 Wellspring Avenue SE, Ste. 105 Rio Rancho, NM 87124 505-415-0462 Officemanager@mvpedsdental.com
