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Oral Health Care for Seniors Outreach Clinic?The Dental Hygiene Students at Georgian College, in partnershihp with the Simcoe Muskoka Integrated Fall Strategy, will be offering Dental Hygiene Services to Seniors in Simcoe County and the District of Muskoka. Services include:Oral health assessments including teeth, gums, dentures, and oral soft tissueOral health educationDenture cleaning Preventive procedures including cleaning and polishing teeth and professional fluoride treatmentX-rays as neededDiagnosis for cavities*All services are provided by Dental Hygiene Students under the supervision of a Registered Dental Hygienist2 appointments are required to complete your care**Each appointment is 3 hours in lengthCOST: one time fee $15 *Please note that we cannot address severe dental needs at this clinic such as dental pain, broken or missing fillings, filling cavities, or denture adjustment, however a diagnosis by a Dentist will be provided. **Additional appointment(s) may be required depending on oral health status.Tuesday Oct (14th & 28th) @ 1 pmFriday Oct (17th & 31st) @ 9 am**Attached forms must be filled in prior to receiving an appointment.Registration InstructionsPlease assist your client to register by following these steps!Client to fill out demographic formClient to sign privacy consent formClient to indicate hip/kee replacement history – need for medical clearancePhysician or Nurse Practitioner to complete medical clearance form if required. Form attached****In accordance with the regulatory requirements of the College of Dental Hygienists of Ontario, it is our policy to obtain medical clearance prior to care when there is any question regarding the client’s health status. At this time, we are specifically referring to a history of joint replacement – Knee or Hip. If this applies to you, please bring the attached Medical Consultation Request to your physician, nurse practitioner or orthopedic surgeon to be completed. ****Office/Organization staff to call Kathy Snider @ 705-721-7520 ext 7068 to book client into prefered clinicOnce appointment is booked, please fax all documents – see belowAll appointments will be held at the Georgian College Sadlon Health & Wellness Centre, Barrie CampusOnce your appointment is booked Fax all forms to: 705 722-1519Or email (Scan if required) to: oralhealthclinic@georgiancollege.caGeorgian College Oral Health ClinicOne Georgian Drive, Barrie, OntarioAll participants are asked to bring a record of any medication that they are currently takingCLIENT DEMOGRAPHICS DENTALLAST NAMEFIRST NAMEDATE OF BIRTHMM/DD/YYSEXADDRESS: STREET NAME #HOME TELEPHONE#CELL TELEPHONE#CITY & POSTAL CODEE-MAIL ADDRESSEMERGENCY CONTACT NAMETELEPHONE #PHYSICIAN: FIRST NAMELAST NAME:ADDRESS: STREET NAMECITY AND POSTAL CODE:TELEPHONE #:FAX #:DENTIST: FIRST NAMELAST NAME:ADDRESS: STREET NAMECITY AND POSTAL CODE:TELEPHONE#:FAX#:I have had a hip or knee replacement? Yes____ No_____**If Yes – Medical clearance is required prior to booking – Form Attached**Information Protection Policy – Sadlon Health & Wellness CentreCONSENT FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION AND PERSONAL HEALTH INFORMATIONPurposes of CollectionI understand that my personal health information is collected and used for the purpose of:Providing me with the most appropriate health careTraining and educating of future health care providers within the clinicPromoting interprofessional practice between clinics and within the Barrie communityInformation SharingI have been informed that Georgian College is a partner with the Barrie Community Family Health Team (BCFHT), and I understand that they share the same Electronic Medical Record system. If my family doctor or nurse practitioner is part of the BCFHT, or if I have visited a Barrie Walk-In Clinic, I understand that a limited amount of my personal health information which is documented by my BCFHT primary care provider (or Walk-in Clinic) is shared with Georgian College Clinics staff and students involved in my care. I further understand that a limited amount of my personal health information which is documented at the Georgian College Clinic is shared within Georgian College Clinics and with my BCFHT primary care provider (or Walk-in Clinic or RVH Emergency). I am aware that if I have questions and or wish to gain clarity on exactly what information is shared that I may do so with clinic staff.PrivacyI understand that Georgian College has a legal obligation to protect patients’ right to privacy and that the collection, use and disclosure of personal health information within Georgian College Clinics is governed by the Personal Health Information Protection Act (2004). I understand that my personal health information will not be shared with individuals who do not have a need to know the information. I have reviewed a summary of the Sadlon Health & Wellness Centre Information Protection Policy and understand how the Information Protection Policy applies to me. AccessI am aware that I have the right to request access to my personal health information and that I may request a correction to my information if the information is inaccurate. ConsentI am aware that I can withdraw my consent for the collection, use or disclosure of my information at any time, but that this withdrawal is not retroactive.I agree to the collection, use and disclosure of personal and health information for the purposes set out in this statement and in the Sadlon Health & Wellness Centre (Georgian College) Information Protection Policy. (The entire Policy is available to you if you wish to review it)_____________________________________________________________________________Patient Name (printed)Patient Date of Birth (mm/dd/yy)_______________________________________________________________Signature of Patient or Substitute Decision MakerDate (mm/dd/yy)_______________________________________________Relationship to Patient (if signing on behalf of patient)NOTES MADE BY Georgian College Clinic personnel: ______________________________________________Medical Consultation Request Date:Client Name: ________________________ DOB: ___________Please complete the form below and return by FAX to: 705 722-1519Georgian College Oral Health ClinicOne Georgian Drive, Barrie, Ontario Telephone: 705 722-5114Georgian College’s Privacy Policy complies with the Personal Health Information Protection ActThe client named above is planning to attend the Georgian College Oral Health Clinic for oral health care. In accordance with the regulatory requirements of the College of Dental Hygienists of Ontario, it is our policy to obtain medical clearance prior to care when there is any question regarding the client’s health status, in this case, a history of joint replacement.It is anticipated that care will consist of non-surgical periodontal therapy which includes scaling and root-planing of teeth causing gingival bleeding.Physician ResponsePlease provide any information regarding the client’s need for antibiotic prophylaxis. OK to proceed with proposed treatment; NO special precautions and NO prophylactic antibiotics are needed. Antibiotic prophylaxis IS required for proposed treatment according to the current American Academy of Orthopedic Surgeons Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures (Dec. 7, 2012). *Royal College of Dental Surgeons of Ontario does not support antibiotic prophylaxis PLEASE PROVIDE CLIENT WITH PRESCRIPTION (refer to next page) DO NOT proceed with treatment. Please give reason: ___________________________OTHER: ________________________________________________________________ _________________________ ________________________ _____________ Physician or RN(EC) name Physician or RN(EC) signature DateClient (Parent/Guardian) ConsentI agree to the release of my personal health information to the Georgian College Dental Clinic for the purpose outlined above.______________________________ __________________________________ ________________Client (Parent/Guardian) name Signature DateTable 1 – Antibiotic Prophylaxis Recommendations (No follow-up dose recommended) Please Note: Prior antibiotic use should be considered before prophylactic antibiotics are prescribed as resistant organisms may develop. If the need for prophylaxis closely follows prior antibiotic exposure (i.e., within 9 to 14 days), an antibiotic from a different antibiotic class should be considered. Situation Agent Regimen* Standard general prophylaxis: Amoxicillin, Cephalexin** 2.0 g orally 30–60 minutes before procedure Unable to take oral medications: Ampicillin Cefazolin 2.0 g IM or IV 30–60 minutes before procedure 1.0 g IM or IV 30–60 minutes before procedure Penicillin-allergic: Clindamycin 600 mg orally 30–60 minutes before procedure Penicillin-allergic and unable to take oral medications: Clindamycin 600 mg IV 30–60 minutes before procedure *No follow-up dose recommended. **Cephalosporins should not be used in individuals with immediate type hypersensitivity reaction (urticaria, angioedema or anaphylaxis) to penicillins. For children, please consult their physician. College of Dental Hygienists of Ontario Guideline (2013). Recommended Antiobiotic prophylaxis for the prevention of infective endocarditis and hematogenous total joint infection ? ................
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