Medical Clearance and Physician Coordination Authorization

Implant and oral surgery is real surgery. Some conditions and medicines change how it should be planned, whether sedation is safe, whether bleeding can be controlled, how well you will heal, and whether it should go ahead at all.

Where any of that applies to you, we ask your physician, cardiologist, oncologist, hematologist, or endocrinologist to confirm what is safe. We are not asking them to plan your dental treatment — we are asking a specific question about your health so that we can plan it responsibly.

• Blood thinners and antiplatelet medicines, or a bleeding disorder.
• Bisphosphonates, denosumab, or other bone medicines — see also the practice's Antiresorptive Medication and Jaw Risk Consent.
• Heart disease, a heart valve, a recent stent, a pacemaker or defibrillator, or a recent heart attack or stroke.
• Diabetes, especially where control is uncertain.
• Cancer treatment, chemotherapy, radiotherapy to the head or neck, or immune-suppressing medicine.
• A joint replacement, an organ transplant, kidney or liver disease, or a seizure disorder.
• Pregnancy, or the possibility of pregnancy.
• Obstructive sleep apnea or any condition that affects sedation safety.

We will share only what your physician needs in order to answer: what procedure is planned, what anesthesia or sedation is intended, and the relevant part of your dental and medical history. We will not share anything unrelated to that question.

I authorize Center for Implant Dentistry to request and receive information about my medical condition, medications, and fitness for dental surgery and sedation from the physicians and other health care providers named below, and to disclose to them the dental information described above for that purpose.

This authorization may be revoked in writing at any time, except to the extent the practice has already acted on it. Information disclosed to a recipient who is not a health plan or health care provider may no longer be protected by federal privacy law and may be redisclosed. Treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization except where the law specifically permits — but a procedure may be postponed if the practice cannot obtain the information it needs to proceed safely.

Unless revoked sooner, this authorization expires one year from the date signed, or on completion of the treatment it relates to, whichever comes first. I am entitled to a copy of this signed authorization.