As her prenatal care provider, I give my permission for

• Patient First and Last Name
• Patient date of birth

to receive any needed dental care, at any time during her pregnancy. This includes oral examinations, dental prophylaxis, scaling and tooth planning, extraction, dental radiographs with lead shielding and local anesthetics with epinephrine such as Lidocaine, Bupivacaine, Mepivacaine.

I recommend acetaminophen for pain management after dental procedures. If you must use opioids, please prescribe the lowest dose for the shortest duration (usually less than 3 days).

Please feel free to contact me with any further questions, or if you believe more complex care coordination might be required.

Thank you,