Referral Form For Pregnant Women To Receive Dental Care printable pdf download

Referral Form For Pregnant Women To Receive Dental Care

Referral Form for Pregnant Women to Receive Dental Care

Referred to: ___________________________________________ Date: __________________

Patient’s Name: (First)____________________________________(Last): _________________

Known allergies: _______________________________________________________________

Estimated delivery date: __________ Week of gestation today: ________

Precautions: ___ None

Specify if any: _________________________________________________________________

______________________________________________________________________________

Patient may have (check all that apply):

Acetaminophen with codeine for pain control

Alternative pain control medication

Please Specify:

Amoxicillin

Cephalosporins

Clindamycin

Erythromycin (not estolate form)

Penicillin

Local Anesthetic with epinephrine

Other, specify

Name:_____________________________________Date: _______________ Phone: _________

Signature: _____________________________________________________________________

Do not hesitate to call with questions

Adapted from: Kumar J, Samelson R, eds. (2006). Oral Health Care During Pregnancy and

Early Childhood: Practice Guidelines. Albany, NY: New York State Department of Health.

Accessed on May 17, 2009

Referral Form For Pregnant Women To Receive Dental Care