Contributing Writer 
Dental Clearance Letter
Name
Address
City, State ZIP
(or preferably print on letterhead)
Dental Clearance Letter — Please Give To Your Dentist
DATE
Re: __________________________________________ DOB: ______________________
To Whom It May Concern:
We have requested that the above candidate provide us with documentation of their current dental health status. This letter will be an important part of the application process.
Please complete the area below, and return this letter to us as soon as possible.
Sincerely,
(Name)
(Address)
(Fax number)
Date of last dental exam: _____________
__ Applicant has no current dental problems that need treatment.
__ Applicant has dental conditions that have not been treated.
Dentist name (please print): _________________________________
Dentist signature: _________________________________________
Date: __________________________
