special patient clinic dental referral form · special patient clinic dental referral form ......
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Special Patient Clinic Dental Referral Form
IMPORTANT: This medical data form is to refer a patient with complex medical conditions and/or physical needs to be screened for an initial assessment visit for acceptance into Special Patient Clinic. This form DOES NOT guarantee a referred patient to the Special Patient Clinic at the School of Dentistry. INSTRUCTIONS: Please complete the following pages by entering the patient’s information and medical conditions as well as your referral information. Incomplete referrals will be voided. You have several options to submit your referral:
Electronically through our Secure Portal 1. Email us for instructions at: [email protected] 2. Provide us with the name of your office in the email 3. Response to your email will include instructions 4. A separate email will be sent with link to our secure portal
Fax to 713-486-4322
Mail to address:
UTHealth School of Dentistry ATTN: HIM RE: MDF 7500 Cambridge, Suite 1310 Houston, TX 77054
Thank you for referring your patient. If you have any questions, please contact our clinic at 713-486-4296.
Special Patient Clinic
Medical Data Form
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Attending Physician/Primary Care Provider
*** Please answer the questions below and print legibly. This is a medical screening questionnaire and requires a complete update by
patient’s attending physician or primary care provider prior to patient receiving comprehensive dental care. ***
Patient Information
Personal Last Name: _____________________________ First Name: _____________________________ Middle: ______
Date of Birth: ________________________ Sex: Male Female Transgender
Primary Phone#: ___________________________________ Home Work Mobile Other: _________
Address: ______________________________________________________________________________________
City: _______________________________ State: _________________ Zip Code: _________________________
Emergency Contact Information
Last Name: _____________________________ First Name: _____________________________ Middle: ______
Phone#: ___________________________________ Other#: ___________________________________
Relation: (Select one) Child Guardian Parent Sibling Spouse Other
Medical Conditions
Please indicate if the patient has (or have had) any of the following diseases, problems, or symptoms and provide details, as applicable, such as severity and how well the conditions are controlled.
Cardiovascular System:
Infective Endocarditis Heart Attack CAD CHF
Atrial Fibrillation Cardiac Arrhythmia Pacemaker Pneumatic Fever
Heart Murmur Mitral Valve Prolapse DVT Stroke
Other: ______________________________________________________________________________________
______________________________________________________________________________________________
Renal/GI Systems:
Cirrhosis/Liver Disease Hepatitis/Jaundice Colitis Crohn’s Disease
GERD Renal Disease:
Hemodialysis or Peritoneal Dialysis
Other: ______________________________________________________________________________________
______________________________________________________________________________________________
Respiratory System:
COPD/Bronchitis Asthma Pneumonia Tuberculosis
Other: ______________________________________________________________________________________
______________________________________________________________________________________________
Special Patient Clinic
Medical Data Form
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Muscular/Skeletal System:
Arthritis Osteoporosis Gout Motor Disabilities
Other: ______________________________________________________________________________________
______________________________________________________________________________________________
Endocrine System:
Diabetes Thyroid Disorder Other: ________________________________________
______________________________________________________________________________________________
Immunologic System:
Autoimmune Disorder Organ Transplant Other: __________________________________
______________________________________________________________________________________________
Neurologic/Psychiatric System:
Epilepsy/Seizure (Type and last occurrence): ________________________________________________________
CNS Disorder Cerebrospinal Shunt Parkinson’s Disease Autism
Cerebral Palsy Communication Disorders Depression Anxiety Disorder
Other: ______________________________________________________________________________________
______________________________________________________________________________________________
Oncologic System:
Cancer or Neoplasia (Type and location): __________________________________________________________
Radiation (Amount): ___________________________ Chemotherapy Steroid Therapy
Other: ______________________________________________________________________________________
______________________________________________________________________________________________
Hematologic System:
Bleeding Disorder
Hemophilia A Hemophilia B Von Willebrands
Idiopathic Thromobcytopenia Purpura (ITP) Medication Induced
Other: ______________________________________________________________________________________
______________________________________________________________________________________________
Other:
Special Patient Clinic
Medical Data Form
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Medications
List of all current medications and herbal supplements.
***Attach for more***
Name: Dose:
(mg)
Frequency: For what condition?
Special Patient Clinic
Medical Data Form
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Additional Information
1. Any drug allergies? No Yes
If yes, please explain: _________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
2. Patient’s Mobility Status: Ambulant Stretcher/Bed Patient Wheelchair
3. What is your medical evaluation with regard to the patient’s ability to undergo oral health care that may include dental
cleaning, restorations, root canals, and/or oral surgery under local anesthesia? (may include use of nitrous oxide)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
4. Do you recommend antibiotic pre-medication prior to dental treatment? No Yes
If yes, please explain the condition, reason, type, and dosage: _________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Provider Information
Doctor Name: ___________________________________ Entity: ______________________________________
Phone: ____________________________________________ Fax: _____________________________________
Email: _______________________________________________________________________________________
Address: _________________________________________ City: ______________ State: _____ Zip Code: _______
Doctor Signature: ___________________________________ Date: _______________