If you wish, use the form below to record information to give to your dentist and oncologist or urologist.
Dental Consultation Form
Dentist's Name: ______________________ Phone No:___________________
Oncologist/Urologist's Name: ___________________ Phone No:___________________
About My Cancer Treatment
Diagnosis (Disease & Stage): __________________________________________
Date of Diagnosis: _________________________
Past and Planned Treatments (Date): ____________________________________
__________________________________________________________________
__________________________________________________________________

❑ Surgery (Site):_____________________________________________________

❑ Radiation Therapy (Site):_____________________________________________
❑ Chemotherapy
Drugs:
❑ Immunotherapy or Other Biological Therapy
(Treatments): _______________________________________________________
❑ Steroids ❑ Bisphosphonates
❑ Other Cancer Treatments (Please List)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
About My Dental Procedures
Date of Last Complete Dental Exam: _________________________
Current and Planned Treatments (Date):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
❑ Wisdom Teeth Extraction or Other Dental Surgery
❑ Periodontics or Other Gum Surgery
❑ Braces or Other Orthodontics
❑ Root Canal Therapy          ❑ Sealants
❑ Dental Implants ❑ Fillings
❑ Dentures ❑ Bridges
❑ Caps, Bonding, Veneers   ❑ Tooth Contouring or Shaping
❑ Crowns ❑ Bleaching
❑ Other Dental Procedures (Please List):
__________________________________________________________________
__________________________________________________________________
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