Dr. Johnny Wong Surgery Intake Form

Name:

As it is listed on your health card.

First Name

Last Name

Preferred Name:

Sex assigned at birth:

Male, female, intersex, etc.

Gender:

Pronouns:

She/Her, He/Him, They/Them, etc

OHIP Number:

e.g. 9876543225 AB

Primary Phone Number:

Please do not include dashes, spaces, or brackets.

Is your primary phone a cell phone?

Yes

Is your primary phone number the ONLY number our office should use to contact you?

By checking yes, you acknowledge we will be deleting all other previous/different phone numbers from your file Note: If you are also a patient of a Magenta Health physician, your file there will automatically be updated as well.

Yes

Secondary Phone Number:

Please do not include dashes, spaces or brackets.

(###)

###

####

Current Address:

Your address MUST match the address on file with the Ministry of Health (i.e. the same address registered to your health card)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I have already scheduled an intake appointment for ...:

Only individuals with who have booked an intake appointment should complete this form. Any other submissions will be deleted immediately without review.

YYYY

Primary Email:

Email Consent:

We use email as a fast, clear, and largely reliable way of communication. May we include health information when emailing you? Sample messages that include health information would be messages to ask you to book a follow-up appointment, to let you know your results are normal, or to share details of a referral to a third-party. For clarity, we do not send marketing newsletters or sell your email address to third parties. Please see below for a discussion of the risks, conditions, and instructions for email. *Email Communication* Risks of using email Transmitting patient information by email poses several risks of which patients should be aware. You should not agree to communicate with us via email without understanding and accepting these risks. The risks include, but are not limited to, the following: - The privacy and security of email communication cannot be guaranteed. - Employers and online services may have a legal right to inspect and keep emails that pass through their system. - Email is easier to falsify than handwritten or signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email once it has been sent. - Emails can introduce viruses into a computer system, and potentially damage or disrupt the computer. - Email can be forwarded, intercepted, circulated, stored or even changed without our knowledge or permission. - - Email senders can easily misaddress an email, resulting in it being sent to many unintended and unknown recipients. - Email is indelible. Even after the sender and recipient have deleted their copies of the email, back-up copies may exist on a computer or in cyberspace. - Use of email to discuss sensitive information can increase the risk of such information being disclosed to third parties. - Email can be used as evidence in court. *Conditions of using email* We will use reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined above, we cannot guarantee the security and confidentiality of email communication. Thus, patients must consent to the use of email for patient information. Consent to the use of email includes agreement with the following conditions: -Emails to or from the patient concerning diagnosis or treatment may be made part of the patient’s medical record. Because they are part of the medical record, other individuals authorized to access the medical record, such as staff and billing personnel, will have access to those emails. - Email communication is not an appropriate substitute for clinical examinations. The patient is responsible for following up with our emails and for scheduling appointments where warranted. - If the patient’s email requires or invites a response from us and the patient has not received a response within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the email and when the recipient will respond. - We are not responsible for information loss due to technical failures associated with the patient’s email software or internet service provider. * Instructions for communication by email* To communicate by email, the patient shall: - Limit or avoid using an employer’s or other third party’s computer. - Review the email to make sure it is clear and that all relevant information is provided before sending to us, including the purpose of the email and the name of the patient. - Take reasonable precautions to preserve the confidentiality of emails. - Withdraw consent only by email or written communication to us.

Yes

Kindly review and acknowledge the following (Risks Involved With Virtual Appointments):

Some appointments with the physician may be conducted using video, rather than in-person. Some health concerns can be addressed with virtual care alone, but in some cases your doctor may ask you to visit a hospital or other health care facility if necessary, for a physical examination. We do our best to make sure that any information you give to us during virtual care visits is private and secure, but no video or audio tools are ever completely secure. There is an increased security risk that your health information may be intercepted or disclosed to third parties when using video or audio communications tools. To help us keep your information safe and secure, you can: - Understand that emails, calls, or texts you receive are not secure in the same way as a private appointment in an exam room. - Use a private computer/device (i.e., not an employer's or third party's computer/device), secure accounts, and a secure internet connection. For example, using a personal and encrypted email account is more secure than an unencrypted email account, and your access to the Internet on your home network will generally be more secure than an open guest Wi-Fi connection. You should also understand that electronic communication is not a substitute for in-person communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed (including for any urgent care that may be required). If you are concerned about using video or audio tools for virtual care, we can let your referring doctor know that you would like to visit a different healthcare provider where you can be seen in person. However, please note that visiting a health care provider in person comes with a higher risk of coming into contact with COVID-19 and the possibility of spreading the virus. By providing your information, you agree to let us collect, use, or disclose your personal health information through video or audio communications (while following applicable privacy laws) in order to provide you with care. In particular, the following means of electronic communication may be used: email, videoconferencing, text messaging, website/portal.

Yes (I have reviewed and acknowledged the above)

Kindly review and acknowledge the following (Dr. Johnny Wong is not a Magenta Physician):

1. Magenta Health Inc. ("MHI") is a medical management company that owns and operates one or more clinics under the brand name MAGENTA HEALTH (the "Magenta Health Clinics"). 2. MHI is not permitted to, nor does it, provide medical services to patients, including myself. 3. Physicians practicing at Magenta Health Clinics (such as the physician you are here to see today) are qualified independent medical practitioners providing medical services to patients directly, or via a medicine professional corporation as authorized under the laws of the Province of Ontario. 4. Physicians practicing at Magenta Health Clinics may receive some administrative assistance or support, but for the most part, operate their own practice. 5. If I consented to email communication, I have read and understood the attached discussion of the risks of email communication. 6. I understand that I will be contacted via the information above and confirm that my contact information is correct and up-to-date.

Yes ( I have reviewed and acknowledge the above)

When did you start gender-affirming hormone therapy (MM/YYYY)?

When did you start living in a gender role that is congruent with your gender identity (i.e. socially transition) (MM/YYYY)?

Which surgery are you applying for (e.g. mastectomy)?

What is your occupation?

What is your marital status?

Do you have children?

Alcohol Consumption:

Do you consume alcohol? If yes, how many units of alcohol do you drink per week? (beer: 12oz/355ml , wine 5oz/150ml, liquor 1.5oz/45ml)

Tobacco Use:

Do you smoke tobacco? If yes, how many packs/day for how many years?

Recreational drug use:

Do you use drugs for recreation? If yes, what kind and how often?

Are you pregnant or planning to be soon?

Yes

N/A

Do you have, or have you ever had any of the following: uncontrolled hypertension, uncontrolled diabetes, uncontrolled dyslipidemia, stroke, blood clots, clotting/bleeding disorders, anemia, liver disease, seizures, migraines, kidney disease or failure, cancer, lung disease, autoimmune conditions?

Can write 'none of the above' or 'not applicable'

If you listed any of the above conditions, please provide additional details including: diagnosis, age of diagnosis, current status of condition (treated/untreated), full name/type of specialists (if any):

Additional Medical/Psychiatric Conditions (Past & Present):

e.g. 1. Seasonal allergies, 2010, treated, Dr. Firstname Lastname, specialty 2. Hypothyroid, 2000, treated, Dr. Firstname Lastname, specialty

Past Surgeries:

Medications, Prescriptions, Vitamins, Supplements, Regularly used over-the-counter Medications. Include strength, dose, and frequency:

e.g. Amoxicillin 300 mg three times a day

Do you have any allergies? If so, what was the reaction?

e.g. amoxicillin: rash

Has anyone in your family had any of the following: blood clots, clotting/bleeding disorders, autoimmune conditions, cancer, porphyria?

Can write 'none of the above' or 'not applicable'

If you listed any of the conditions in the family history section above please provide additional details if known, including: family member's relationship to you, diagnosis, age of diagnosis, results of any genetic testing done:

e.g. Maternal grandpa: 78 years old, colon cancer, no genetic testing

Please do not enter arbitrary information for the surgeon's details (e.g. random numbers for the fax number) as it is required information for your surgery application. Without the correct details, there will be delays to your application. If you are not sure about any of the requested information below, we kindly ask that you contact the surgery facility directly.

I understand

Proposed health facility/hospital name for surgery:

Name of physician or contact person at proposed health facility/hospital (first and last name):

Address of proposed health facility/hospital (note that out-of-country surgeries may be rejected by the Ministry if the surgery is not usually covered by OHIP):

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number of proposed health facility/hospital:

Please do not include spaces, dashes, or brackets

Fax number of proposed health facility/hospital:

Please do not include spaces, dashes, or brackets

I understand Dr. Wong does not provide family medicine or primary care services:

Yes

I understand this form will NOT be reviewed by a medical professional prior to my scheduled appointment:

Yes

I understand I will not be a patient until after my appointment has been completed:

Yes

SURGERY READINESS intake form
(Medical History and Contact Authorizations for Appointment with Dr. johnny wong)

Submission received, thank you!

SURGERY READINESS intake form(Medical History and Contact Authorizations for Appointment with Dr. johnny wong)

Submission received, thank you!

SURGERY READINESS intake form
(Medical History and Contact Authorizations for Appointment with Dr. johnny wong)