Spectrum Oral Surgery
Mississauga 905-279-9971
Georgetown 905-877-0147
Mississauga: Mon-Th 8:30-4:30, Fri 8:30-2:30
Georgetown: Tue-Th 8:30-4:30, Fri 8:30-2:30
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Privacy Code
Our Services
Teeth Extractions
Wisdom Teeth Extractions
Implants
Bone Grafts
Oral Pathology
Orthognathic Surgery
Management of TMD
Meet Our Doctors
Dr. Andy D. Wong
Dr-ron-ho
Refer Patient
Patients Form
Contact us
Menu
HOME
About-us
Privacy Code
Our Services
Teeth Extractions
Wisdom Teeth Extractions
Implants
Bone Grafts
Oral Pathology
Orthognathic Surgery
Management of TMD
Meet Our Doctors
Dr. Andy D. Wong
Dr-ron-ho
Refer Patient
Patients Form
Contact us
Patients Form
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ORAL AND MAXILLOFACIAL SURGEONS
ANDY WONG, D.D.S., F.R.C.D.(C)
RON HO, D.D.S., F.R.C.D.(C)
PLEASE PRINT CLEARLY
Name
First
Last
ADDRESS:
APT.#
UNIT#
CITY
POSTAL CODE
HOME PHONE:
BUSINESS:
MOBILE:
EMAIL ADDRESS
Date
MM slash DD slash YYYY
Genderspecify
HEALTH CARD #
VERSION CODE
NEXT OF KINCLOSEST RELATIVE
RELATIONSHIP
HOME TEL
WORK TEL
MOBILE TEL
REFERRAL INFORMATION
REFERRED BY: (CIRCLE ONE) DENTIST/ DOCTOR/ SPECIALIST/ OTHER
NAME
PHONE
REGULAR DENTIST
PHONE
FAMILY DOCTOR
PHONE
Medical History questionnaire
NAME: MR./MISS/MRS./MS.
Last
DOB
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain.
Yes
No
Not SureMaybe
If yes, please explain.
2. When was your last medical checkup?
3. Has there been any change in your general health in the past year? If yes, please explain.
Yes
No
Not Sure/Maybe
If yes, please explain.
4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list them.
Yes
No
Not Sure / Maybe
If yes, please list them.
5. Do you have any allergies If yes please list them using the categories below
Yes
No
Not Sure/Maybe
a) Medications
b Latex rubber products
c) Other (e.g. seasonal/environmental, foods)
6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.
Yes
No
Not Sure/Maybe
7. Do you have or have you ever had asthma?
Yes
No
Not Sure/Maybe
8. Do you have or have you ever had any heart or blood pressure problems?
Yes
No
Not Sure/Maybe
9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?
Yes
No
Not Sure/Maybe
10. Do you have a prosthetic or artificial joint?
Yes
No
Not Sure/Maybe
11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?
Yes
No
Not Sure/Maybe
12. Have you ever had hepatitis, jaundice or liver disease?
Yes
No
Not Sure/Maybe
13. Do you have a bleeding problem or bleeding disorder?
Yes
No
Not Sure/Maybe
14. Have you ever been hospitalized for any illnesses or operations? If yes, please explain.
Yes
No
Not Sure/Maybe
If yes, please explain.
15. Do you have or have you ever had any of the following? Please check.
chest pain,
therapy
disease
angina
seizures
diabetes
rheumatic
(epilepsy)
mitral valve
fever pacemaker
heart attack
prolapse
steroid
lung
kidney
disease stroke
TIA tuberculosis
stomach ulcers thyroid disease
shortness of breath
heart murmur cancer
arthritis
drug/alcohol/
cannabis osteoporosis use or dependency
meds (e.g. Fosamax, Actonel)
16. Are there any conditions or diseases not listed above that you have or have had? If yes, please explain.
Yes
No
Not Sure/Maybe
If yes, please explain.
17. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)?
Yes
No
Not Sure/Maybe
18. Do you smoke or chew tobacco products?
Yes
No
Not Sure/Maybe
19. Are you nervous during dental treatment?
Yes
No
Not Sure/Maybe
20. Are you breastfeeding or pregnant?
Yes
No
Not Sure/Maybe
If pregnant, what is the expected delivery date?
MM slash DD slash YYYY
21. Do you identify as a patient with a disability? If yes, please explain.
Yes
No
Not Sure/Maybe
If yes, please explain.
To the best of my knowledge the above information is correct.
Patient/Parent/Guardian Signature:
Date
MM slash DD slash YYYY
Dentist Signature:
Date
MM slash DD slash YYYY
Insurance Information
CDAnet and You
Electronic Claims Submission is a reality in our office. This service has been developed jointly by some insurance carriers and your oral surgeon to offer better service to you.
Electronic Claims Submission saves you the effort and cost of mailing the insurance form yourself-your oral surgeon is providing this service for you. As well, your claims processor will be able to process your claim faster, which means that reimbursement to you will be received in a timely fashion.
Primary Insurance Information
Name of patient
Name of policy holder
Date
MM slash DD slash YYYY
Insurance company
Policy Group
Subscriber ID Certificate
Relationship of patient to policy holder Dependent
Spouse
(Secondary Insurance Information) Name of policy holder
Policy holder’s date of birth
MM slash DD slash YYYY
Insurance company
Policy Group
Subscriber ID / Certificate #
Relationship of patient to policy holder Dependent
Dependent
Spouse
******************Please inform us if you have triple coverage**************************
AUTHORIZED CONSENT TO RELEASE INFORMATION
“I authorize release, to my dental benefits plan administrator, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of service described to the named oral surgeon.”
Signature of patient, parent or guardian.
Date
MM slash DD slash YYYY
FINANCIAL POLICY
**********PLEASE READ CAREFULLY AND SIGN**********
Our fees are in accordance with the current Ontario Dental Association’s Oral and Maxillofacial Surgeons suggested fee guide. If you have dental insurance, we will gladly electronically submit a pre-determination (estimate) for you. We will submit all claims electronically for you. The insurance company will pay you directly; we do not accept direct payment from the insurance company. All fees will be due at the time of treatment. We accept Visa, MasterCard, Amex, Interac, and Cash. We do not accept personal cheques.
Please check which one applies to you:
FNANCIAL AGREEMENT for INSURED PATIENTS
I understand that an insurance claim form will be submitted electronically by the office. I am aware I will receive one of two forms, either a “claim acknowledgement form” or an “explanation of benefits” form. I have been informed that the predetermination is just an estimate and that the final fee will be determined at the time of surgery based on the difficulty of surgery. I understand that it is my responsibility to cover the costs of all treatment rendered by the oral surgeon, and that I am financially responsible for the full amount of the account. I understand that any concerns regarding the fees that the insurance company may or may not cover must be discussed with the surgeon prior to the surgery date.
FINANCIAL AGREEMENT for NON-INSURED PATIENTS
I will be given a written estimate and am aware that it is just an estimate. I understand that it is my responsibility to cover the costs of all treatment rendered by the oral surgeon, and that I am financially responsible for the full amount of the account.
FINANCIAL AGREEMENT for GOVERNMENT ASSISTED PLANS
Our office does not extra bill or bill for balances not paid under the government assisted plan. We do bill the patient for services not covered and not paid for under the plan. Payment must be made at the time services are performed.
PERSON RESPONSIBLE FOR ACCOUNT
REALTIONSHIP TO THE PATIENT
Signature
Date
MM slash DD slash YYYY
Privacy Form
PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION
• By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed on the back of this consent. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.
• Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue.
• Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and for your specific consent. • When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate.
• You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.
Patient Consent
I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information.
I know that your office has a Privacy Code, and I can ask to see the Code at any time. I agree that Spectrum Oral Surgery can collect, use and disclose personal information about (patient’s name)
(patient’s name) as set out above in the information about the office’s privacy policies.
Patient/Parent/Guardian Signature
Print name
Date
MM slash DD slash YYYY
Signature of Witness
PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION
• Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients.
• In this office, Dr. Andy Wong acts as the Privacy Information Officer.
All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.
Attached to this consent form, we have outlined what our office is doing to ensure that:
• Only necessary information is collected about you;
• We only share your information with your consent;
• Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols;
• Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.
Do not hesitate to discuss our policies with me or any member of our office staff.
Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.
How Our Office Collects, Uses and Discloses Patients’ Personal Information
Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information.
This office will collect, use and disclose information about you for the following purposes: • to deliver safe and efficient patient care
• to identify and to ensure continuous high quality service
• to assess your health needs
• to provide health care
• to advise you of treatment options
• to enable us to contact you
• to establish and maintain communication with you
• to offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally
• to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists
• to allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments
• to allow us to efficiently follow-up for treatment, care and billing
• for teaching and demonstrating purposes on an anonymous basis
• to complete and submit dental claims for third party adjudication and payment
• to comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
• to comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes • to permit potential purchasers, practice brokers or advisors to evaluate the dental practice
• to allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
• to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any
• to prepare materials for the Health Professions Appeal and Review Board (HPARB)
• to invoice for goods and services
• to process credit card payments
• to collect unpaid accounts
• to assist this office to comply with all regulatory requirements
• to comply generally with the law
PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION
• Privacy of your personal information is an important part of our office providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and transparent as possible about the way we handle your personal information. It is important to us to provide this service to our patients.
• In this office, Dr. Andy Wong acts as the Privacy Information Officer.
All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.
Attached to this consent form, we have outlined what our office is doing to ensure that:
• Only necessary information is collected about you;
• We only share your information with your consent;
• Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols;
• Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law.
Do not hesitate to discuss our policies with me or any member of our office staff.
Please be assured that every staff person in our office is committed to ensuring that you receive the best quality dental care.
How Our Office Collects, Uses and Discloses Patients’ Personal Information
Our office understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined here how our office is using and disclosing your information.
This office will collect, use and disclose information about you for the following purposes: • to deliver safe and efficient patient care
• to identify and to ensure continuous high quality service
• to assess your health needs
• to provide health care
• to advise you of treatment options
• to enable us to contact you
• to establish and maintain communication with you
• to offer and provide treatment, care and services in relationship to the oral and maxillofacial complex and dental care generally
• to communicate with other treating health-care providers, including specialists and general dentists who are the referring dentists and/or peripheral dentists
• to allow us to maintain communication and contact with you to distribute health-care information and to book and confirm appointments
• to allow us to efficiently follow-up for treatment, care and billing
• for teaching and demonstrating purposes on an anonymous basis
• to complete and submit dental claims for third party adjudication and payment
• to comply with legal and regulatory requirements, including the delivery of patients’ charts and records to the Royal College of Dental Surgeons of Ontario in a timely fashion, when required, according to the provisions of the Regulated Health Professions Act
• to comply with agreements/undertakings entered into voluntarily by the member with the Royal College of Dental Surgeons of Ontario, including the delivery and/or review of patients’ charts and records to the College in a timely fashion for regulatory and monitoring purposes • to permit potential purchasers, practice brokers or advisors to evaluate the dental practice
• to allow potential purchasers, practice brokers or advisors to conduct an audit in preparation for a practice sale
• to deliver your charts and records to the dentist’s insurance carrier to enable the insurance company to assess liability and quantify damages, if any
• to prepare materials for the Health Professions Appeal and Review Board (HPARB)
• to invoice for goods and services
• to process credit card payments
• to collect unpaid accounts
• to assist this office to comply with all regulatory requirements
• to comply generally with the law
