Fax

To:	From:
Fax:	Date:	November 22, 2017
Phone:	Pages:
Re:	CC:

X Urgent	For Review	Please Comment	X Please Reply	Please Recycle

•Comments:

Our mutual patient, ________________, Date of Birth,___________, has a prosthetic joint, and may need premedication for dental procedures. Please respond by selecting from the following:

Patient needs premedication

Patient does not need premedication

__________________________	_____________

Signature	Date