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[Doctor=s letterhead]
Date: Fax No. __________________
Dear Dr. , this fax will confirm our conversation of today
wherein we discussed your patient and his/her
condition(s) of
_____________________________________________________________________
_____________________________________________________________________
and our proposed treatment of
_____________________________________________________________________
[ ] with local anesthesia [ ] with epinephrine [ ]with [ ] without IV Sedation
scheduled for . In response, you recommended the
following:
_____________________________________________________________________
_____________________________________________________________________
.
Thank you for your advice in this matter. Please immediately advise us before the
next business day if this letter is not accurate or if the patient=s condition should
significantly change before our scheduled treatment/operation as noted above.
Otherwise we will proceed as noted and will assume the foregoing is a correct
statement of your advice.
[Doctor=s Name]
THE DOCUMENT BEING FAXED IS INTENDED ONLY FOR THE USE OF THE INDIVIDUAL OR
ENTITY TO WHICH IT IS ADDRESSED, AND IT MAY CONTAIN INFORMATION THAT IS PRIVILEGED,
CONFIDENTIAL, AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW.
IF THE READER OF THIS MESSAGE IS NOT THE INTENDED RECIPIENT, YOU ARE
HEREBY NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION, OR COPYING OF THIS
COMMUNICATION IS STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS COMMUNICATION IN
ERROR, PLEASE NOTIFY US IMMEDIATELY BY TELEPHONE, AND RETURN THE ORIGINAL
MESSAGE AT THE ABOVE ADDRESS VIA THE UNITED STATES POSTAL SERVICE.