DOB To Whom It May Concern: Dr. Mubashir Mumtaz, MD, FACS Chief, Cardiovascular & Thoracic Surgery Dr. David Loran, MD Cardiovascular Surgeon Our mutual patient noted above is scheduled to undergo heart valve surgery at PinnacleHealth. Prior to surgery, it is important to verify that the patient has had a dental exam within the past 6 months, has no current dental infection and no anticipation of dental care within the next 6 months excluding restoration. This letter.
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How to fill out the PinnacleHealth Form 1422-23 online
This guide provides you with clear instructions on how to complete the PinnacleHealth Form 1422-23 online effectively. By following these steps, you can ensure that all necessary information is accurately entered for submission.
Follow the steps to fill out the PinnacleHealth Form 1422-23 online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the patient's name and date of birth in the designated fields labeled 'Re' and 'DOB.' Ensure this information is accurate as it is crucial for identifying the patient.
- In the section addressed to 'Whom It May Concern,' fill in the information of the healthcare providers, including the names 'Dr. Mubashir Mumtaz, MD, FACS' and 'Dr. David Loran, MD'.
- Confirm the medical details regarding the patient's dental exam by checking the appropriate fields that state if the patient has had a dental exam within the past 6 months, has no current dental infection, and does not anticipate any dental care needs within the same period.
- In the final section, print the name of the dentist in the specified area, followed by the required signature and date of the examination.
- Once all fields are filled, review the form for accuracy. After ensuring all information is correct, you can save the changes, download the form, print it, or share it as needed.
Complete your PinnacleHealth Form 1422-23 online today!
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