THE PRINCE PHILIP DENTAL HOSPITAL
菲臘牙科醫院

Surgical Consent Form
手術同意書

1. I (HKID Card / Passport Number)
本人 (Name in Block Letters) (請用正楷填寫姓名) (香港身份證 / 護照號碼)

hereby consent to myself / my child* undergoing the operation of
茲同意本人 / 子女* (Name of minor under 18) (十八歲以下子女姓名) 接受

脫牙 18 and the administration of local or other anaesthetics.
手術及施行局部或其他麻醉。

2. The nature, purpose, risks and complications of the surgery have been explained to me by the following
person(s) :
有關手術之性質、效果、風險及可能引起之併發症已由以下人士向本人清楚解釋 :
醫生

RN/CDSA 傳譯

3. I also consent to further or alternative operative measures as may be found to be necessary or advisable
during the course of this operation.
手術期間，如須施行進一步或另一項手術，本人亦同意進行。

4. I understand that no assurance has been given that the operation will be performed by any particular
dental surgeon.
本人更明悉該項手術並無特別保證由某位牙科醫生施行。

I am /am not* willing to allow the extracted teeth or other tissues of myself / my child* to be used for research.
本人願意 / 不願意* 讓本人 / 子女* 脫下之牙齒或其他組織作為研究用途。

16-01-2020
Date
日期

*Please delete as appropriate 請將不適用者刪去
PPDH 302 (Revised 16.9.04)


The Prince Philip Dental Hospital 菲臘牙科醫院
Health Declaration 健康申報表

Name 姓名:  Identification Document No.
身份證明文件號碼 :
Phone Contact Record No. (if any)
聯絡電話: 病歷編號 (如適用) :

A. SYMPTOMS 病徵 NO 無 YES 有 If Yes, number of days 如有，日數
1. Fever 發燒 (>37.5C) N
2. Chills & Tremors 發冷 N
3. Cough 咳嗽 N
4. Diarrhoea 肚瀉 N
5. Shortness of Breath / Difficulty in Breath N
呼吸急促 / 呼吸困難
6. Sore Throat 喉嚨痛 N
7. Malaise 精神萎靡 N
8. Myalgia 肌肉痛 N
9. Other Symptoms (Please specify)
其他病徵 (請列明)

Please provide the following information 請提供以下資料 :
B. Have you ever been diagnosed with COVID-19? (If yes, please specify name of hospital admitted and
date of discharge) 曾否確診 2019 冠狀病毒病? (如有，請列明入住醫院及出院日期)
No

C. Travel history within past 14 days (Please specify the dates and city / province / country)
過去十四天內的旅遊紀錄 (請列明日期和城市 / 省份 / 國家)
No

D. Have you visited hospitals or quarantine camp, or been in close contact with person(s) who is/are inbound
travellers* or identified as suspected carriers/ confirmed patients suffering from COVID-19 within past 14
days? (Please specify name of hospitals/ quarantine camp/ countries and cities visited)
過去十四天內曾否到訪醫院或隔離營或與海外抵港人士*或 2019 冠狀病毒病疑似帶菌者或確診病
患者有密切接觸? (請列明醫院/隔離營/到訪國家及城市)
No

E. Have you been in a 14-day self-quarantine within past 2 months? (If yes, please specify the period)
過去兩個月內曾否接受自我隔離十四天? (如有，請註明日期)
No

Declaration 聲明:
1. I hereby declare that all information provided above is true and accurate. 本人證實上述資料正確無訛。
2. I hereby authorise The Prince Philip Dental Hospital or its representatives to obtain my medical records of the past 2 months
from relevant health departments/ agencies of the HKSAR Government and agree to provide necessary information in
relation to the application of the records. 本人授權菲臘牙科醫院或其代表可向香港政府有關衞生部門或機構索取本
人最近兩個月的病歷紀錄，並會提供申請紀錄時所需要的資料。
3. The above data may be sent to the relevant health departments/ agencies of HKSAR Government for appropriate follow-up
actions. 以上資料可能會交予香港政府有關衞生部門或機構作出跟進。

Signature 簽名 : Date 日期 : 11 MAR 2021
[If you are signing for the patient, please 為父母或監護人替病人簽署，請提供以下資料:
(i) Name in BLOCK letter 姓名:____________________;
(ii) Identification Document No. 身份證明文件號碼:____________________; (iii) Relationship with patient 與病人之關係:____________________]

*Family members, friends or relatives co-living in the same residency who have been visiting or studying abroad and returned to Hong Kong in the past 14 days
過去 14 天內曾到訪其他國家或留學返港的同住家庭成員、朋友及親戚


Date DAY SHEET Initials
15, 16, 17 grossly carious and TTP.
Tx: explained need for 15, 16, 17 removal.
Informed of risks of OAC, maxillary sinusitis,
ORN.
advised to seek private dentist for restoration of
other carious teeth asap and to improve OH.
17 JUL 2020 OMFS CONSULT
PATIENT CANCELLED APPOINTMENT
14 AUG 2020 OMFS CONSULT
PATIENT CANCELLED APPOINTMENT
12 OCT 2020 OMFS CONSULT
PATIENT FAILED APPOINTMENT
Patient declined extractions, will seek private dental
care. Discharge from OMFS


Print at: 2020-01-16
Page No.: 1

Patient Appointment Summary
Hospital No.:
Appointment Date: 2020-01-16 14:30
Name:
Clinic: 750

Progress Note

Chief Complaint
Refer from RPC for the extraction of 18,28.

History of Present Complaint
Pain on 18.

Clinical Exam
18 PE
28 extracted last week, wound healing satisfactory.

Treatment
Extraction of 18.
Explained the risk of root fracture and oral-antral communication.
Informed consent obtained.

LA: 2% xylestesin 1:80000 adrenaline , B and P local infiltration. 1 cart.
18 removed with warwick james elevator.

Hemostasis achieved.

POi given.
Rx: Paracetamol 500mg qid prn po X 4 tabs

To Come Again
Discharged. From OMFS

Operator Signature:

2020-01-16


康頤牙科醫務中心
Mark & Richard Dental Centre

Referral Letter
Date: 2020年12月2日

Oral and Maxillofacial Surgery - Consultation Clinic

2/F, The Prince Philip Dental Hospital
34 Hospital Road, Sai Ying Pun, Hong Kong
Tel: 2859 0263/ 2859 0387

Dear Doctor,

Re:                                                                  M / 65

Please kindly see the above named patient who is suffering from right side tooth pain. Mr
Leung had history of nasopharyngeal cancer and had undergone treatment. Multiple root
caries were found. OPG was taken, multiple teeth were found unrestorable. Referral to
OMFS and prosthodontic care was suggested.

Please kindly give your expert management.

OMFS E8 JAN 2021.
Staff                                                                  4/2/2021
HDO
JHDO
BDS               IV   V   VI
Signature                                                 MDS III    18/2/2021
                                                                                2:00


handwriting_text:
previous NPC — completed RT last year.
Hypertension under medication
had shingles last year.
03, 01, 2019
Previous smoker 20 - 30 year ~ 1 pack / day.

1. Poor General Health 健康不良: N

2. Current Medical Treatment 是否正在接受醫藥治療: Y

3. Medicine Pills or Tablets 是否服食任何藥物: Y

4. Previous Hospital Experience 入住醫院或在醫院「門診部」接受治療: Y

5. General Anaesthetic 「全身麻醉」: N

N

7. Hay Fever, Eczema, Asthma 「乾草熱」、「濕疹」或「哮喘」: N

8. Rheumatic Fever 「風濕性熱病」: N

9. Abnormal Bleeding 施手術、脫牙或受傷時是否流血不止: N

Y

11. Jaundice, Hepatitis or Other Liver Disease 「黃膽病」、「肝炎」或其他「肝病」: N

12. Fainting or Giddiness 突然暈倒或常覺頭暈: N

13. Childhood Diseases 曾否患「水痘」、「麻疹」、「風疹」、「痄腮」等症: N

14. Expectant Mother 是否懷孕: N

Heart Disease 心臟病: N

Hypertension 高血壓: Y

Blood Disease 血病: N

V.D. 性病: N

Kidney Disease 腎病: N

Diabetes 糖尿病: N

Thyroid Disease 甲狀腺病: N

Other Medical Problems 其他有關健康資料: N

T.B. 結核病 (肺癆): N

Epilepsy 羊癇: N

Stroke 腦充血: N


handwriting_text:
hypothyrodism 3 month review
thyroid supplement
planning for cyst removal
no cyst found before surgery and discharged
no medication need
13 JAN 2020


handwriting_text:
Childbirth
3 / 01 / 2020

2. Current Medical Treatment 是否正在接受醫藥治療: N

3. Medicine Pills or Tablets 是否服食任何藥物: N

Hypertension 高血壓: N