Dental Antibiotic Prescription Form

Patient full name

First NameMiddle NameLast Name

Date of birth

Date

Phone number

Please enter a valid phone number.Format: (000) 000-0000.

Email address

example@example.com

Preferred contact method

Reason for antibiotic request/prescription

Affected tooth or area

Current symptoms

Symptom onset date

Date

Current status

Antibiotic allergies

Current medications

Relevant medical conditions

Pregnancy or breastfeeding status

Prior antibiotic use for this issue

Preferred Pharmacy Name

Preferred Pharmacy Location

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Do you already have a dentist or provider involved in your care?

Follow-Up Preference / Availability