Dental clearance before surgery or treatment: what to send, what comes back

Last updated 2026-11-05. Published by the team behind eReferral, a free referral tracker; see the last section.

Short answer: The team planning the treatment owns the dental clearance until the dentist's report is back in its hands. Send the dental office the team's own form, the treatment date, the date the report is needed by, a fax number and a direct phone. Then confirm the office received it, set a check date, and record the day the signed form comes back. A report arriving is not a clearance: the treating clinician still decides.

On this page:

• Where to get a dental clearance form, and what real ones ask
• How to refer a patient to a dentist before surgery or cancer treatment
• What a hospital dental referral should include
• How the team knows the dentist received it
• Who follows up when the report never comes back
• Tracking dental referrals without a new EHR module
• What a dental office sends back
• What we do not know
• Where eReferral fits, and where it does not

Where to get a dental clearance form, and what real ones ask

Get the form from the team planning the treatment, because its form is the one that counts. If the team has none, a general printable form such as eReferral's free one works as a fallback, and eReferral's own page says to use the team's form when you have it [9].

There is no single form. Each program writes its own, and they differ on the X-ray rule, the time window, who to call and how the form goes back. We opened five published hospital forms on 2026-11-05 and recorded what each asks. We cite them here; we do not reproduce them.

This table shows what those programs ask. It is not a list of who needs a dental evaluation. The treating team sets that, and sets the timing.

What the five have in common:

• All five ask for the dentist's signature and print a fax number [1] [2] [3] [4] [5].
• Three put a number of months on the exam or X-rays [1] [2] [5].
• None has a step where the dental office confirms it received the request [1] [2] [3] [4] [5].
• None sets a return deadline in days. The closest is a request to send it "as soon as possible" [2].

The last two rows of that list are the gap this page is about. The form tells the dentist what to check. It does not tell anyone whether the form arrived, or who calls when it does not come back.

How to refer a patient to a dentist before surgery or cancer treatment

Name one owner, pick the dental office with the patient, and send that office the team's form with the treatment date and a date the report is needed by. Then confirm the office has it and put a check date on the calendar.

Placing an order in the chart does not, by itself, reach a dental office. Someone on the care team, often the coordinator, has to choose the office with the patient and send the request [11].

If the patient has a dentist, start there. If not, ask whether your hospital keeps a list of dental offices it works with. Some do and some do not [11].

The handoff, step by step:

1. Get the treating team's own form and the treatment date or week. Cleveland Clinic's forms, for example, ask for the week of the procedure [1] [2].
2. Write one owner's name on the order. A role like "the team" cannot be called.
3. Confirm the dental office with the patient, including its fax number.
4. Send the form, plus the items in the next section.
5. Ask the office to confirm receipt the same day, by phone or reply.
6. Set two check dates: one soon after sending, and one far enough before the treatment date that a second office is still possible.

Timing is the treating team's call. The forms above show how much it varies, from a stated number of months to "current" radiographs [1] [3] [5].

What a hospital dental referral should include

Include what the dental office needs to book the visit and send the report back: the team's form, the reason in plain words, the treatment date, the report needed-by date, a return fax and a phone number for a person. Add the patient's identifiers and medication contact the way your own policy allows.

Each item, and why the forms ask for it:

• The team's own form. Every program above has its own, and the questions differ [1] [3] [4].
• The treatment date or week. Both Cleveland Clinic forms ask for it [1] [2], and the cardiac form counts its X-ray window back from that date [1].
• The date the report is needed by. None of the five forms sets a return deadline in days, so put your own on the cover note [1] [2] [3] [4] [5].
• Where to send it back. All five print a fax number. Cleveland Clinic's cardiac form lists two, one outpatient and one inpatient, so tell the office which applies [1].
• A direct phone for a person. Both Cleveland Clinic forms tell the dentist to call a named doctor if there is a problem [1] [2].
• Medications. The Cleveland Clinic cardiac form sends the dentist to the patient's cardiologist for medication and anticoagulation questions [1]. Name who the dentist should call on your team.
• X-rays. Say what the form requires and whether recent films exist. The forms range from full mouth X-rays or a panoramic film within a set window to "current" radiographs [1] [3].
• Patient name and date of birth. All five forms have a line for the patient's name [1] [2] [3] [4] [5]. Send them through your approved channel.

If the patient asks who pays for the visit, one line covers it: the care team and the patient's plans answer that, so ask before booking.

How the team knows the dentist received it

The team knows only when someone at the dental office confirms it, by phone, by reply, or by marking it received in a shared tracker. A sent fax is not the same as a request that a person at the office has seen.

None of the five published forms we read includes a receipt step [1] [2] [3] [4] [5]. Receipt is left to whoever thinks to call.

That matters because referrals stall early. In a Duke study of 103,737 referral scheduling attempts from primary care to specialists, 38.9% had no appointment date recorded [6]. A request with no booked visit is the first sign that it never landed.

Three ways to confirm receipt:

1. Call the office the day you send, and write down the name of the person who confirmed.
2. Ask for a reply on the cover sheet: "Please call or fax back to confirm you have this."
3. Use a tracked referral. On eReferral, the server records the first time each side opened what the other sent [10]. The people holding the links mark received, scheduled, seen and report sent. These are updates from the people holding the links, not independent confirmation of a visit [11].

Who follows up when the report never comes back

The team that ordered the evaluation follows up, and it needs one named person to do it. If nobody is named, everyone assumes someone else is calling.

The gap is measured. In the Duke study, only 34.8% of referral scheduling attempts ended in a documented completed appointment [6]. In a program run by Brigham and Women's Hospital and Dana-Farber Cancer Institute, community dentists completed every requested part of the dental work before cancer treatment in 144 of 186 dental evaluations, or 77.4% [7]. The authors call that high compliance [7]. That still left 42 evaluations with something unfinished.

The coordinator checklist for the return leg:

1. First check date. Has the office booked the visit? If not, call.
2. No answer by the second check date. Call again, then offer the patient a second office [11].
3. Form returns. Check every field: signature, exam date, X-ray date, every yes or no answered. Cleveland Clinic's form asks the dentist to complete all sections [1].
4. Form says not ready. Note who will do the work and the expected finish date. Allina's form asks for both [3].
5. Record the arrival date and file it where the treating team will look.
6. Hand it to the treating clinician. A form that arrived is not a decision. The clinician decides what happens next [11].

Copy the handoff steps above and these six into your own team's note. Keep the owner's name at the top.

Tracking dental referrals without a new EHR module

You can, with a named owner, a short log and two check dates. The log needs only the sent date, the date the office confirmed, the visit date, the date the report came back and the date it closed.

A shared log works if one person reads it on a schedule. The tool matters less than the habit of looking at what is overdue.

If you want a tracker outside the chart, eReferral's desk is one free option. A desk is one coordinator, one private link and one list, showing where each referral stands and how long it has waited, with no account [8].

A referral there holds no patient name. Every field is a choice from a list, a date or a code the server makes [8]. It does hold the time of each step, the visit date and the dentist's one line finding [10].

Two cautions from eReferral's own reviewer page. If your team pastes a track code into a patient's chart, your organization can link the record to that patient, so ask your privacy officer first [10]. eReferral does not offer a business associate agreement for the free tracker [10].

What a dental office sends back

Send back the hospital's own form with every section filled in, signed and dated, to the fax number printed on it. If the patient is not ready, say what needs doing, who will do it and when it should be finished.

The return, item by item:

• The hospital's form, not a letter of your own, when one was given. The free eReferral form is for when none was given [9].
• Exam date and X-ray date. Four of the five forms ask for the exam date [1] [2] [3] [4].
• Every yes or no answered, with nothing left blank.
• If not ready: findings, recommended treatment, who will do it and the expected date. Allina asks for findings, who will do the work and when [3]; OHSU asks for the recommended treatment [4].
• Your name, credentials and signature. OHSU also asks for practice name and phone [4].
• A call if you find a problem. Both Cleveland Clinic forms ask the dentist to call a named doctor [1] [2].
• A copy for your chart, and the date you faxed it.

If the request came with an eReferral link or code, open it with no account, send the report your usual way, then mark it sent [8]. eReferral never carries the report itself [10].

What we do not know

We could open five forms today. We tried a Nebraska Medicine dental clearance form and a Dana-Farber dental clearance form at their published links, and both returned "not found" on 2026-11-05, so they are not in the table.

The two Cleveland Clinic forms word their 6 month window differently [1] [2]. Ask the team which date the count starts from.

Forms change. Each row shows the revision date printed on it where one exists. A form we read today may be replaced next month.

We do not know how many hospitals use a paper form versus an order in the chart. We also have no data on how long dental offices take to return a form.

The two studies we cite measured other settings: Duke's covered referrals to specialists [6], and the Brigham and Dana-Farber work covered one program [7]. Neither measured dental clearance across hospitals.

Where eReferral fits, and where it does not

eReferral fits the gap between sending the request and getting the report back. It tracks six stops: sent, received, scheduled, seen, report back and closed [8].

What it does, from its own pages:

• Free for dentists and patients, and nobody pays to be listed or to receive a referral [8].
• The dentist answers from a link, or types the eight character code from the printed sheet, with no account [8].
• A coordinator's desk lists every referral and how long each has waited [8].
• A read only track page shows where a referral stands to anyone with the hospital and the track code [10].
• Referrals are deleted 180 days after the last activity [10].

What it does not do:

• It does not carry the dental report, and it does not notify anyone about a referral [10].
• It does not pick the dentist [8].
• The dentist's finding is a fixed choice and is "Not a clearance" [10]. Closed does not mean anyone is cleared for treatment [8].
• Statuses are reported by the people holding the links, not independent proof of a visit [11].
• It offers no business associate agreement and makes no claim to meet any hospital's policy [10].

Next step: Start a free tracked referral on ireferral.org and get one link to follow and one to give the dental office [8].

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