Dear Doctor:

I am planning to initiate treatment for your patient.

Please advise me if there is anything in the patient's medical history of which I should be aware. Are there any contra-indications with regards to medication?

We have the following information listed for:

Specific treatment could involve the following:

	Deep cleaning of the gum and teeth.
	Office surgical flap procedure (1cm incisions) closed with sutures.
	Codeine medication
	Zylocaine anesthetic containing epinephrine
	Local Carbocaine or lidocaine injectable nerve block
	Transient bacteremias
	Dental apprehension
	Diet interruptions
	Localized bleeding and discomfort could be involved

Thank you in advance for your help.

Sincerely,

M. Jeffrey Morton, D.M.D., P.A.
Specialty License #2770

Patient's Signature to Authorize Release of Information___________________Date_________