Medical Consultation Request PDF Details

If you are like many people, you may not have time to go to the doctor for every little ache or pain. For less serious issues, a medical consultation request form can be a great way to get the information and advice you need without having to leave home. This type of form can be found online, and typically asks for your name, contact information, the nature of your inquiry, and other relevant details. Once you have filled out the form, a doctor or other healthcare professional will review it and respond with advice or a possible course of treatment.

Here is the data relating to the file you were in search of to fill out. It will tell you how much time you will need to complete medical consultation request, what parts you will have to fill in and a few other specific facts.

Form NameMedical Consultation Request
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesform, MetLife, dissemination, 50ml

Form Preview Example



Pacific Dental School

To: Dr.__________________________________

Please complete the form below and return it to



Dr. ___________________________________













Date of Birth







Our patient has presented with the following medical problem(s):________________________________






The following treatment is scheduled in our clinic:_____________________________________________




Most patients experience the following with the above planned procedures:



minimal (<50ml)

significant (>50ml)


stress and anxiety:






Dentist’s signature



Please provide any information regarding the above patient’s need for antibiotic prophylaxis, current cardiovascular condition, coagulation ability, and the history and status of infectious diseases. Ordinarily, local anesthesia is obtained with 2% Lidocaine, 1:100,000 epinephrine. For some surgical procedures, the epinephrine concentration may be increased to 1:50,000 for hemostasis. The epinephrine dose NEVER exceeds 0.2 mg total.


OK to PROCEED with dental treatment; NO special precautions and NO prophylactic antibiotics are needed .

Antibiotic prophylaxis IS required for dental treatment according to the current American Heart Association and/or American Academy of Orthopedic Surgeons guidelines.

Other precautions are required: (please list)________________________________________________


DO NOT proceed with treatment. (Please give reason)_______________________________________


Treatment may proceed on (Date)_________________

Patient has an infectious disease:

AIDS (please provide current lab results)

Hepatitis, type ______, (acute/carrier)

TB (PPD+/active)

Other (explain)___________________

Requested relevant medical and/or laboratory information is attached.



Physician Signature



I agree to the release of my medical information to the above named dentist office.



Patient Signature


This Medical Consultation form is created and maintained by the University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, California. Support for the translation and dissemination of the Health Histories comes from MetLife Dental.

How to Edit Medical Consultation Request Online for Free

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Step 2: You can now edit your coagulation. Our multifunctional toolbar allows you to include, remove, change, and highlight content material or perhaps perform similar commands.

Enter the requested material in every single section to fill in the PDF coagulation

cardiovascular spaces to fill in

You should provide the crucial details in the Antibiotic prophylaxis IS, andor American Academy of, Other precautions are required, DO NOT proceed with treatment, Treatment may proceed on Date, Patient has an infectious disease, AIDS please provide current lab, Hepatitis type acutecarrier, Requested relevant medical andor, Physician Signature, Date, PATIENT CONSENT, I agree to the release of my, Patient Signature, and Date area.

Filling out cardiovascular stage 2

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