Medical Clearance I HEREBY AUTHORIZE THE DOCTOR TO RELEASE ANY NEEDED INFORMATION REGARDING MY HEALTH CONDITIONS TO LEADING EDGE DENTAL.Patient Name*Date* Physician's NamePhysician's PhonePhysician's FaxReason for Medical ClearanceDoes patient need pre-med? If so, what is recommended?How many days should patient start back on his/her coumadin/aspirin?What type(s) of anesthetic do you recommend?What type(s) of pain medication do you recommend?Medical clearance requested byMedical clearance faxed byPhysician Signature*Please enter full name.Date*
