Premedication & Medical Clearance | Luxury Tooth Booth Inc.

1. Patient and Representative Information

Patient Full Legal Name *

Patient Date of Birth *

Patient Phone Number

POA / Guardian / Authorized Representative Name, if applicable

Representative Role or Authority

Representative Phone Number

2. Premedication Screening

Some patients may receive individualized instructions from a dentist, physician, cardiologist, orthopedic surgeon, or other treating provider to take antibiotics before certain dental procedures.

ADA guidance: The American Dental Association states that relatively few patients need antibiotic prophylaxis before dental procedures. In general, preventive antibiotics are not recommended solely because a patient has a prosthetic joint. For selected patients with certain highest-risk cardiac conditions, prophylaxis may be appropriate before procedures involving manipulation of gum tissue, the tooth-root area, or perforation of oral mucosa. Read the ADA's Antibiotic Prophylaxis guidance.

Yes — a provider has instructed the patient to take antibiotics before dental procedures.

No — the patient has not been instructed to take antibiotics before dental procedures.

Not sure — please contact the treating provider if clarification is needed.

Reason for premedication instruction or need for medical clarification, if known

Relevant history, if known

Prosthetic or artificial heart valve

Heart-valve repair using prosthetic material

History of infective endocarditis

Congenital heart condition

Cardiac transplant with valve disease

Joint replacement with special surgeon instruction or history of complication

Immune suppression, transplant, cancer treatment, or other complex medical condition

Other medical or surgical reason

Reason not known

3. Medication and Antibiotic Allergy Information

If antibiotics have been prescribed before dental treatment, list the medication name, dose, timing, and prior side effects, if known.

Does the patient have any known antibiotic allergy, intolerance, or prior adverse reaction? *

If yes or not sure, list the medication and describe the reaction, if known.

4. Treating Provider / Surgeon Contact Information

Please provide the clinician who manages the condition related to premedication or medical clearance. Luxury Tooth Booth Inc. may use this information to clarify current instructions, treatment precautions, or medical-clearance needs.

Treating Provider or Surgeon Full Name

Medical Specialty

Practice, Hospital, or Medical Group Name

Provider Office Telephone Number

Provider Office Fax Number, if known

Provider Office Email Address, if known

Provider Office Address, if known

Date of Most Recent Visit With This Provider, if known

5. Permission to Verify Instructions

Yes — I authorize Luxury Tooth Booth Inc. to contact the provider or office listed above, as needed, to clarify medical history, premedication needs, treatment precautions, or medical clearance for the patient's care.

No — I do not authorize contact with the outside provider at this time. I understand that declining communication may limit the provider's ability to confirm precautions or safely proceed with some services.

Not applicable — no outside-provider contact is needed at this time.

I understand that Luxury Tooth Booth Inc. may need to verify premedication instructions, medication allergies, medical-clearance needs, or treatment precautions before services are rendered. *

I understand that the final decision to prescribe or recommend antibiotic prophylaxis belongs to an appropriately licensed prescribing clinician, based on the patient's individual medical condition and current professional guidelines. *

I understand that care may be postponed, modified, or referred if necessary safety information or instructions cannot be verified. *

6. Attestation and Electronic Signature

I confirm that the information supplied is accurate and complete to the best of my knowledge. I will notify Luxury Tooth Booth Inc. of changes in the patient's medical condition, treating providers, medication list, or premedication instructions.

Name of Person Signing *

Signer Role *

Date Signed *

Electronic Signature *

By typing your full legal name, you intend to sign this form electronically.