One of the requirements of the hospital before your child’s dental surgery at Island Hospital is to obtain a medical checkup by his/her primary care provider within 30 days (before) of the surgery. This will ensure that your child is healthy and ready to go. It will also inform the anesthesiologist (the doctor who will help keep your child asleep) about their particular medical history and address any family issues with anesthesia.

You should schedule this appointment as soon as possible. Please let us know the date of this appointment, so we can coordinate the surgery schedule. If surgery is delayed beyond the 30 day “window”, then your child will need an “interval note,” based on a quick re-exam, by your child’s medical provider.

Please print out the following form and take it with you to your child’s pre-surgical appointment.

Required Hx and Physical