Dr. Cardenas/Fernandez Dental formFernandez Dental Office
8180 N.W. 155 St. Suite 200
Miami Lakes, Fl. 33016
(305) 512-9250
Fax (305) 512-9257
Dear Doctor, ~
Your patient ~ ~ Ci ~~~ r ~~ ~c'l~~as come to our office requesting dental
treatment, which will involy possible emotional stress and oral bleeding. We need your
medical opinion of this patient. Please advice us if this patient at this time can undergo
such treatment. Also, note if you recommend any special precautions as listed below.
What is the patients condition?
L~ What medications are being taken by the patient?
m/ Any problems with coagulation that may interfere with extraction and/or oral
surgical procedure?
~Y Pre and Post operative medication necessary (antibiotics)?
Could we use epinephrine?
i~ Any special post-operative instructions?
We follow this procedure in the best interest of the patient. If you would like to
discuss further treatment, please feel free to call us at the number above.
,I, ~' ~,.._ . _ _
yori f your c operation, --- -..~
^ zaro aernandez, D.D.S ~,(,_Jj (~ ~~
^ ys brera, D.M.D
^ Cecil a Crosby, D.D.S
I have evaluated this patient to be medically sound for the appropriate dental
treatment.
rr ~ !~~
~" J
7~ ~ L v) .
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