Part A · Completed by the referring clinician

Patient name

Date of birth

TAJ number (patients in Hungary)

Referring clinician, specialty and institution

Phone and e-mail for the report

Question to be answered

Diagnosis (BNO / ICD-10)

Planned treatment and date

Relevant medication

Anticoagulant or antiplatelet · drug and dose
Bone-modifying drug · drug, route, interval, start date
Immunosuppressant or steroid
Chemotherapy or radiotherapy · start date, dose to the jaws

Allergies and previous reactions

Relevant results (INR, blood count, HbA1c …)

Antibiotic prophylaxis required Yes · regimen: No

Urgency Routine Treatment date within 4 weeks

Patient’s signature

Date · signature · stamp

Part B · Completed by Johanna Dental and returned to you

Examination date and imaging used

Findings

Outcome

No active dental infection found on clinical and radiographic examination
Treatment needed · expected completion by
Treatment completed on (date) · last invasive procedure on (date)
Patient declined the recommended treatment

Recommendations and questions for you

This opinion reflects the clinical and radiographic findings on the examination date. It cannot guarantee that no infection is present or that none will develop later.

Treating dentist · date · signature · stamp