PLEASE MARK THE AREA TO BE TREATED

Please verify teeth for extraction:

RECENT RADIOGRAPHS

Patient Carrying

Mailed

Emailed
Date Taken:

Please Take X-rays

Upload X-rays:

Upload More X-rays:

Wheelchair

Non-English Speaking

Physical/Mental Disabilities

Requires POA

Does the patient require antibiotic prophylaxis prior to dental procedures? Yes No

If YES please include type and dose of antibiotic prescribed

Does this patient take blood thinners? Yes No
If YES, which blood thinner:

Is patient on a bisphosphonate? Yes No

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