Edit, Download, and Sign the Dental Clearance for Surgery Form
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How do I fill this out?
To fill out the dental clearance form, start by entering the patient's personal information at the top. Next, complete sections related to the patient's dental history, including dates of operations and examinations. Finally, ensure that both the dentist's signature and office stamp are present for validation.
How to fill out the Dental Clearance for Surgery Form?
1
Enter the patient's name and date of birth.
2
Fill out the dates for operations, examinations, and teeth cleaning.
3
Indicate whether the patient has any dental infections.
4
Provide the dentist's signature and stamp.
5
Review all information for accuracy before submission.
Who needs the Dental Clearance for Surgery Form?
1
Patients requiring heart surgery need this form to ensure dental health is assessed.
2
Dentists need this form to provide a detailed evaluation of the patient's dental status.
3
Surgeons need the form to confirm that their patients are safe for surgery.
4
Medical office staff require this to organize surgical clearances effectively.
5
Insurance companies may need this form to approve claims related to surgical procedures.
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1
Open the PDF in the PrintFriendly editor.
2
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What are the instructions for submitting this form?
To submit the completed form, fax it to the designated surgical office at (415) 833-4390 or email it to surgicalteam@kaiserpermanente.org. Ensure that the submission includes the dental office stamp and signed clearance. It is advisable to keep a copy of the form for your records.
What are the important dates for this form in 2024 and 2025?
Important dates for using this form include the deadline for dental clearance, which should ideally be two weeks prior to the surgery date. Ensure that the dental examination is completed within six months before the surgery. Keep an eye on annual updates to the form, which may occur each fiscal year.
What is the purpose of this form?
The purpose of this form is to ensure that patients are free from any acute dental infections before undergoing heart surgery. By requiring dental clearance, the surgical team minimizes the risk of complications during the procedure. This form serves as a formal document that communicates the dental health status of the patient to the surgical team.
Tell me about this form and its components and fields line-by-line.
- 1. Patient's Name: The full name of the patient.
- 2. Date of Operation: Scheduled date for the surgical procedure.
- 3. Date of Dental Examination: When the patient last underwent a dental examination.
- 4. Date of Last Teeth Cleaning: Date when the patient's teeth were last professionally cleaned.
- 5. Dental Office Stamp/Card: Stamp or card of the dental office to verify authenticity.
- 6. Dentist's Signature: Signature of the dentist providing the clearance.
- 7. Date: The date when the dentist signed the form.
- 8. Dentist's Printed Name: The full name of the dentist.
- 9. Dental Office Phone #: Contact number of the dental office.
- 10. Dental Office Fax #: Fax number of the dental office.
What happens if I fail to submit this form?
Failure to submit this form may lead to delays in scheduling the patient's surgery. Without this clearance, the surgical team cannot proceed with the operation, potentially putting the patient's health at risk. It is crucial that this form is completed accurately and promptly.
- Surgical Delay: Without dental clearance, the surgery may be postponed.
- Health Risks: Existing dental infections pose risks during anesthesia.
- Increased Complications: Dental issues can lead to complications during recovery.
How do I know when to use this form?
- 1. Pre-operative Assessment: To ensure dental health is evaluated before surgery.
- 2. Compliance with Medical Guidelines: Needed for adherence to surgical protocols.
- 3. Coordination between Dental and Medical Teams: Facilitates communication regarding patient care.
Frequently Asked Question
What is this form used for?
This form is used to obtain dental clearance for patients prior to heart surgeries.
Who fills out this form?
It should be filled out by the patient's dentist and verified by the surgical team.
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Do I need to print the form?
No, you can edit and save the form digitally.
What information is required on the form?
The form requires personal details, dental history, and signatures.
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Yes, support is available through our contact page for any assistance.
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