Smile Dental Clinic

SMILE DENTAL CLINIC
86 Luis Palad St. Angustias Zone 1 (Prob), Tayabas City

Phone Number: (0939) 255 2607
E-Mail: 2051200@aup.edu.ph
DENTAL REFERRAL LETTER

Specialist:
Dela Cruz, Abegail C. DMD
Address: 86 Luis Palad St. Angustias Zone 1 (Prob), Tayabas City
Phone No: (0939) 255 2607
E-mail: 2051200@aup.edu.ph
Patient Details:
Name: Marvelous Dela Cruz Address: Brgy. Ilayang Wakas, Tayabas City
Age: 24
Birthday: 20 July 1999 Phone No: 09123456789
Gender: Male
Occupation: Seafarer
To Dr. Gregory Adea
Respectfully referring my patient Mr. Marvelous Dela Cruz for preoperative risk assessment
for he will undergo dental implant.
cc. “gusto ko po magpa-implant, kasi po nahihirapan po ako sa pustiso ko”

HPI: 2 years ago the patient had undergo tooth extraction of his upper right first and second
premolar as well as the left first molar and had removable partial denture.
Upon consultation the patient is asymptomatic.
Assessment:
Dental: Missing upper right first and second premolar as well as the left first molar.
Medical: Px is diagnosed with ischemic heart disesase.
Px is taking aspirin 80 mg once a day.
Px is also taking isordil 5 mg once a day.
Treatment: Dental implant on upper right first and second premolar as well as the left first molar
under LA lignocaine with epinephrine 1:100000.
Pre- operative treatment: Hold or stop the aspirin first.
Post operative medication: Ibuprofen 200 mg PO q4-6hr
Please advise for any modification of the tentative treat plan.

Kindly send back px with written medical clearance.
Thank you so much.
Abegail C. Dela Cruz, DMD SMILE DENTAL CLINIC

License No.: 2051200
Phone Number: (0939) 255 2607
Specialist:
Phone No: (0939) 255 2607
Patient Details:
Name: Joy Adea Address: 021 Biga II, Silang, Cavite
Age: 25
Birthday: 16 May 1997 Phone No: 09987456321
Gender: Female
Occupation: Architect
To Dr. Myrtle Lopez
Respectfully referring my patient Ms. Joy Adea for preoperative risk assessment and clearance.
cc. “gusto ko po mag pabunot, kasi po nasakit ngipin ko sa baba”

HPI: 1 year ago, the px saw that there is a black discoloration in her tooth specifically on the right
lower 1st molar. The px experienced a throbbing pain that lasted 10 seconds. However, the px did
nothing. Intervene consultation, the px experienced a sharp pain that last for 5 seconds still the px
did nothing.
Upon consultation the px has a badly broken-down tooth but asymptomatic.
Assessment:
Dental: Badly broken-down tooth no. 46

Medical: Px has resistant hypertension. Usual blood pressure of 150/90 mm Hg.
Px is taking telmisartan 80 mg once a day, compliant
Treatment: Removal of tooth no. 46 with LA mepivacaine 80 mL of 0.5% solution.
Preoperative medication: Amoxicillin 500mg PO q12hr
Post operative medication: Paracetamol 500 mg every 8 hrs if there is pain

Thank you so much.
Abegail C. Dela Cruz, DMD SMILE DENTAL CLINIC

Phone Number: (0939) 255 2607
Specialist:
Phone No: (0939) 255 2607
Patient Details:
Name: Judah Celeste Address: B7 L17 Tierra Vista, Langkaan,
Age: 24 Dasmariñ as City, Cavite
Gender: Male
Occupation: MedTech
To Dr. Kristine May Adea
Respectfully referring my patient Mr. Judah Celeste for risk assessment and clearance. In
addition an ECG result for he will be undergoing dental implant.
cc. “gusto ko po magpadental implant kasi lagi po nasisira ang pustiso ko”
HPI: 3 years ago, the patient had an accident which result to a badly broken-down tooth of his right
upper central inscissor.
Upon consultation the px is asymptomatic
Assessment:
Dental: Missing upper right central inscissor.
Medical: The px is diagnosed with rheumatic heart disease, mitral stenosis
The px is taking penicillin 500 mg every 4-6 hours
Treatment: Dental implant of upper right central inscissor with LA mepivacaine 80 mL OF 0.5%
solution
Preoperative medication: Clindamycin 150 mg every 6 hrs
Post-operative medication: Ibuprofen 400 mg PO q46hrs

Thank you so much.
Abegail C. Dela Cruz, DMD

SMILE DENTAL CLINIC
Phone Number: (0939) 255 2607

Specialist:
Phone No: (0939) 255 2607
Patient Details:
Name: Matthew Calpo Address: : Brgy. Ilayang Wakas, Tayabas City
Age: 22
Gender: Male
Occupation: Electrical Engineer
To Dr. Morris Manliclic
Respectfully referring my patient Matthew Calpo for medical risk assessment.
cc. “gusto ko po ipabunot yung ngipin ko kasi di po ako makakain nang maayos dahil sumasakit po
sa tuwing kumakain ako”
HPI: 5 days ago the px experienced a sharp pain everytime he eats that lasts for 8 seconds but did
nothing about it.
Upon consultation the px still experience while eating.
Assessment:
Dental: Badly broken-down tooth no. 16
Medical: The px is diagnosed with anemia. Latest Hemoglobin level is 9 mg/dl.
The px taking iron supplement 500 mg twice daily.
Treatment: Removal of tooth no. 16 with LA mepivacaine 80 mL of 0.5% solution
Preoperative medication: Amoxicillin 500 mg
Post-operative medication: Paracetamol 500 mg every 8 hrs if there is pain

Thank you so much.
SMILE DENTAL CLINIC

Abegail C. Dela Cruz, DMD Phone Number: (0939) 255 2607
License No.: 2051200 E-Mail: 2051200@aup.edu.ph
Specialist:
Phone No: (0939) 255 2607
Patient Details:
Name: Crystalyn Adea Address: 021 Biga II, Silang, Cavite
Age: 24
Birthday: 23 July 1998 Phone No: 09123789456
Gender: Female
Occupation: Civil Engineer
To Dr. Candice Gueta
Respectfully referring Crystalyn Adea for medical clearance if the patient is fit for
undergoing removal of impacted canine.
cc. “gusto ko po magpabunot dahil sa impacted canine ko”

HPI: 1 month ago, the patient experienced pain on his palate and taken radiograph and saw that she
has impacted canine.
Upon consultation the px is asuymptomatic.
Assessment:
Dental: Impacted canine
Medical: Px is diagnosed with diabetes, controlled. Hba1c is 6.5%.
Px is currently taking metformin 500 mg thrice daily
Treatment: Removal of impacted canine under LA lidocaine with epinephrine 1:100
Preoperative medication: Co-amoxiclav 20 mg
Post-operative medication: Paracetamol 500 mg every 8 hrs if there is pain

Thank you so much.
SMILE DENTAL CLINIC

Phone Number: (0939) 255 2607
Abegail C. Dela Cruz, DMD E-Mail: 2051200@aup.edu.ph
Specialist:
Phone No: (0939) 255 2607
Patient Details:
Name: Hrett Celeste Address: Bagong Pag-asa, Paliparan, Dasmariñ as,
Age: 33 Cavite
Birthday: 23 January 1990 Phone No: 09651324789
Gender: Male
Occupation: Electrician
To Dr. Gilbert Susbilla
Respectfully referring Hrett Celeste for medical clearance if the patient is fit for undergoing
removal of impacted canine.
cc. “gusto ko po ipabunot ang aking ngipin kasi ang sakit po kapag kinakagat at madalas po
sumasakit ang aking ulo at panga dahil dito”
HPI: Last 5 months ago, the patient experience a sharp pain when he was eating that lasted for a
day, he also experiences headache the patient just took ibuprofen to relieve pain.
Upon consultation the px still experience sharp pain and the diagnosis of the radiograph shows that
the patient has an impacted canine.
Assessment:
Medical: Px is diagnosed with hyperthyroidism. Last thyroid function test results were normal.
Px is currently taking carbimazole 10 mg once a day.
Treatment: Removal of impacted canine with LA mepivacaine 80 mL of 0.5% solution
Preoperative medication: penicillin 40 mg
Post-operative medication: Ibuprofen 200 mg every 6 hrs for 4 days

Thank you so much.
SMILE DENTAL CLINIC

Phone Number: (0939) 255 2607
Specialist:
Phone No: (0939) 255 2607
Patient Details:
Name: Adrean Quigao Address: 234 Biga II, Silang, Cavite
Age: 45
Birthday: 27 February 1970 Phone No: 09632145986
Gender: Male
Occupation: Accountant
To Dr. Alwyn Lopez
Respectfully referring my patient Adrean Quigao for medical clearance if he is fit to undergo
impacted canine extraction.
cc. “gusto ko po ipabunot ang ngipin ko kasi sobrang sakit po kapag natatamaan at nahihirapan na
din po ako ibuka ang aking bibig dahil sa sakit.
HPI: Last month, the patient experience a sharp pain that lasted for a day and gradual increase of
difficulty in opening the mouth.
Assessment:
Medical: Px is diagnosed with epilepsy. No recent seizure episodes.
Px is taking lamotrigine 200 mg a day once a day
Treatment: Removal of impacted canine with lidocaine
Preoperative medication: erythromycin 400 mg every 8 hrs and chlorhexidine 15 mL as mouthwash
for 30 seconds
Post-operative medication: Tylenol 500 mg every 8 hrs if there is pain

Thank you so much.
SMILE DENTAL CLINIC

Phone Number: (0939) 255 2607

Specialist:
Phone No: (0939) 255 2607
Patient Details:
Name: Paulo Calingasan Address: 241 BlessedVille, Dasmariñ as, Cavite
Age: 8
Birthday: 14 February 2015 Phone No: 09126453781
Gender: Male
Occupation: Student
To Dr. Katherine Manliclic
Respectfully referring my patient Paulo Calingasan for medical clearance if he is fit to

undergo pulpectomy and composite restoration under general anesthesia.
cc. “sira po ngipin ko at masakit”

HPI: 1 year ago, the patient’s mother stated that the patient has a tooth discoloration but did not do
anything because it is just a baby tooth.
7 days before consultation, the patient experienced throbbing pain, fever and swelling of his gums
on tooth no. 51 and 61
Assessment:
Dental: Abcess on 51, 62, 71, 72, 81, 54 and 64 and there is a gloss distraction on maxillary
dentition.
The patient had done fluoride application.
Medical: The px has diagnosed with cerebral palsy
The px is currently taking phenobarbital 4 mg once daily.
Treatment: pulpectomy on 51 and 61
Composite restoration on both tooth no. 71, 81, 54, 64, 52 and 62 under GA using
proponol 4 mg IV
Preoperative medication: Clydamycine 37 mg three times a day
Post-operative medication: Ibuprofen 10 mg every 8 hrs if there is pain

Thank you so much.
SMILE DENTAL CLINIC

Phone Number: (0939) 255 2607

Specialist:
Phone No: (0939) 255 2607
Patient Details:
Name: James Fernandez Address: Brgy. Lita Phase 1, Tayabas City
Age: 8
Birthday: 10 January 2015 Phone No: 09459786126
Gender: Male
Occupation: Student
To Dr. Margaux Gueta
Respectfully referring my patient James Fernandez for medical clearance.
cc.”sakit po ng ngipin ko”

HPI: According to his mother, the patient experienced a sharp pain 11 months ago. However, she did
not do anything or no medication was taken by the patient.
Upon consultation, the patient is asymptomatic.
Assesment:
Dental: Multiple carries on tooth no. 51, 52, 55, 61, 63, 74, 75
Medical: The px is diagnosed with sickle cell anemia. Recent transfusion was a month ago. Latest
hemoglobin level of 10 mg/dl.
Treatment: Composite restoration on tooth no. 51, 52, 55, 61, 63, 74, 75.
And fluoride application with GA under nitrous oxide with 50% oxygen

Thank you so much.


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SMILE DENTAL CLINIC

86 Luis Palad St. Angustias Zone 1 (Prob), Tayabas City

DENTAL REFERRAL LETTER

To Dr. Gregory Adea

cc. “gusto ko po magpa-implant, kasi po nahihirapan po ako sa pustiso ko”

Upon consultation the patient is asymptomatic.

Please advise for any modification of the tentative treat plan.

Abegail C. Dela Cruz, DMD SMILE DENTAL CLINIC

To Dr. Myrtle Lopez

cc. “gusto ko po mag pabunot, kasi po nasakit ngipin ko sa baba”

Upon consultation the px has a badly broken-down tooth but asymptomatic.

Dental: Badly broken-down tooth no. 46

Please advise for any modification of the tentative treat plan.

Abegail C. Dela Cruz, DMD SMILE DENTAL CLINIC

To Dr. Kristine May Adea

Upon consultation the px is asymptomatic

Please advise for any modification of the tentative treat plan.

Abegail C. Dela Cruz, DMD

DENTAL REFERRAL LETTER

To Dr. Morris Manliclic

Respectfully referring my patient Matthew Calpo for medical risk assessment.

Upon consultation the px still experience while eating.

Please advise for any modification of the tentative treat plan.