Dental Clearance Form Template

Surgeons and referring offices need a clear yes or no before a procedure. This dental clearance form template captures patient details, oral findings, and clearance status so the care team is not chasing paper faxes.

Great for

• Dentists clearing patients before surgery or medical procedures
• Oral surgeons documenting pre-op dental status for referring MDs
• A clinic link instead of a scanned paper clearance letter

State the planned procedure and the clearance decision in plain language. List precautions only when they change how the surgical team should prepare.

Share the form with the clearing dentist. Export CSV when the surgical office needs a dated record in the chart.

Formms is not built for HIPAA-covered records. If your organization is a covered entity, use a HIPAA-compliant platform for this workflow instead.

Questions in this template

1. Patient full name *
   Name
2. Date of birth *
   Date
3. Reason for clearance / planned procedure *
   Short text
4. Oral health status *
   Dropdown Healthy, no acute issues, Treated, ready for procedure, Active infection or unresolved issues, Needs dental treatment before clearance
5. Clearance decision *
   Dropdown Cleared for the planned procedure, Cleared with precautions below, Not cleared at this time
6. Precautions, antibiotics, or notes *
   Long text
7. Dentist name *
   Name
8. Dentist signature *
   Signature
9. Today's date *
   Date