Medical Order Request

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DENTIST/MEDICAL PROVIDER

PATIENT'S NAME:

RESIDING AT:

BECAUSE OF THE PATIENT'S DISABILITY AND/OR INABILITY TO TRAVEL AND BE TREATED IN ADENTAL OFFICE, THE PATIENT MAY HAVE ORAL HYGIENE SERVICES PERFORMED BY SUSANDRAGOO, RDHAP, ALTERNATIVE CARE DENTAL HYGIENE PRACTICE, AND ASSOCIATES,INCLUDING ORAL SCREENING, ORAL PROPHYLAXIS, PERIODONTAL SCREENING, NON-SURGICALPERIODONTAL THERAPY, ORAL CARE PLAN, AND ANY OF THE FOLLOWING: CHLORHEXIDINEGLUCONATE PRN, LIP BALM PRN, FLUORIDE TREATMENT PRN, ORAQIX TPICAL (2%LIDOCAINE/2% PRILOCAINE) PRN, 20% BENZOCAINE TOPICAL PRN.

DOES THIS PATIENT HAVE ANY MEDICAL CONCERNS THAT WOULD REQUIRE ENDOCARDITISPROPHYLAXIS?

Yes

IF YES, PLEASE LIST PATIEN'TS MEDICAL CONDITION:

KNOWN ALLERGIES:

PHYSICIAN/DENTIST LICENSE NUMBER:

DEA NUMBER:

I am authorized by the Physician/Dentist to complete this referral