MEDICAL RELEASE
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Email *
Patient's Name
 *
Patient's Date of Birth *
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Today's Date *
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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 Address
 *
Parent/Guardian E-Signature *
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 Patient *

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

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