Sample Forms


  • In 2009, the forms in this page were drafted by Dr Suhaila Jaffar, then in 2014, they were approved by all the Pediatric Dental Clinic Heads.
  • All the forms have been printed and distributed by the Pediatric Dental Department in 2015.

This form is used to communicate with the pediatrician and obtain consultation for any medically compromised and/or special needs patient.

In this form we have to specify the dental treatment that the patient requires for example:
6-year-old male patient with down syndrome requires multiple restoration and extraction using lidocaine with epinephrine in the dental clinic / or under general anesthesia, please kindly evaluate this patient and advise us about any necessary precautions which need to be taken, regards .