Referral For Physician’s Evaluation

 

Our dental patient,

 

___________________________________________

 

(date of birth: _____________________)

 

 

has informed us that the following condition is present:

 

  ______________________________________

 

The patient will be having dental procedures done that may create a transient septicemia.

 

Please evaluate the patient's records to confirm the need for prophylactic antibiotic premedication before high risk dental procedures, and return the next page with your recommendation.  Thank you!

 

Sincerely,

 

Randy Otterholt, D.D.S.

 


 

Please return to:

Randy Otterholt, D.D.S.
6817 N. Cedar Rd, Suite 102
Spokane, WA  99208-4277
Fax (509) 328-9902

 

Dr. Otterholt:

I have evaluated the records of our mutual patient ( _____________________________ ), and advise the following:

 

___ No prophylactic antibiotic premedication is needed.

 

___ 2 grams  Amoxicillin orally one hour before treatment as per American Heart Association and the American Academy of Orthopaedic Surgeons.

 

___ 600mg  Clindamycin orally one hour before treatment as per American Heart Association and the American Academy of Orthopaedic Surgeons.

 

___ 2g  Cephalexin or Cefadroxil orally one hour before treatment as per American Heart Association and the American Academy of Orthopaedic Surgeons.

 

___ 500mg Azithromycin or Clarithromycin orally one hour before treatment as per American Heart Association.

 

___ Other:     ________________________________________________

                   __________________________________________________

                   __________________________________________________

 

 

_______________________________________
Physician

 

_______________________
Date