HKU Dentistry
香港大學牙醫學院
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Teaching Patient's Declaration
教學病人聲明

In connection with the initial examination and subsequent treatments / consultation (if any) at The Multi-Specialty Clinic of the Institute for Advanced Dentistry (IAD-MSC) of myself / my child / the person concerned, I hereby declare (on behalf of my child / the person concerned) that:

  1. I have read and fully understood the “Notice to Members of Public Who Intend to Seek Dental Treatment from IAD-MSC (version dated 2018.10)” and “Statement of Collection of Personal Information from Patients” before registration;
  2. I hereby consent to and authorise IAD-MSC or University of Hong Kong / third-parties to use all or any anonymized photographs, radiographs, scan images or study models taken of me / my child / the person concerned, for the purposes of education, research records and/or publication;

Functions of IAD-MSC

  1. I understand that IAD-MSC is a teaching clinic and will not provide public dental services. All treatments of teaching patients are wholly geared to the training of Postgraduate students of Faculty of Dentistry of The University of Hong Kong (the Faculty), dental ancillary students, or staff of the Faculty / IAD-MSC;

Initial Examination Process

  1. I / My child / The person concerned agree(s) to be examined in the course of a screening process. I understand that IAD-MSC will not provide any dental treatment or follow-up if I / my child / the person concerned have / has not been accepted as a teaching case after examination. In that case, I will accept without any claim against IAD-MSC that I / my child / the person concerned shall have to seek further dental or medical attention or treatment elsewhere;
  2. I understand that waiting time for the screening and examination process may vary, and that there is no guarantee that admission as teaching patient would be offered to me / my child / the person concerned. I understand that, during the period of the screening and examination process and before I / my child / the person concerned am / is accepted as a teaching patient, IAD-MSC will not provide any dental treatment or follow-up. Should any symptom or health condition arise during such period, I / my child / the person concerned should promptly seek treatment dental or medical attention or treatment elsewhere in order to avoid any health risk resulting from delay in seeking treatment;
  3. I am aware that the initial examination is likely to be time-consuming and will usually require a whole morning or afternoon session;

Subsequent Treatment / Consultation Arrangements (if any)

  1. If I am / my child / the person concerned is accepted as a teaching patient, I understand that the waiting time will depend on the needs of the relevant teaching programmes and the nature and type of the dental problems, varying from several weeks to several years, and that during such waiting period I / my child/ the person concerned should consider seeking dental or medical attention or treatment elsewhere in order to avoid any health risk resulting from delay in seeking treatment;
  2. I understand that in view of the teaching requirements, each appointment for treatment / consultation is likely to be time-consuming and will usually require a whole morning or afternoon session;
  3. I understand that IAD-MSC has the absolute right to cease further treatment or follow-up if IAD-MSC considers that the dental problems of me / my child / the person concerned are no longer suitable for teaching purposes or for further examination by IAD-MSC. In that case, I accept without any claim against IAD-MSC that I/ my child/ the person concerned shall have to seek further dental or medical attention or treatment elsewhere;
  4. I accept without any claim against IAD-MSC that IAD-MSC has the absolute discretion to discharge me / my child / the person concerned from the care and attention provided at IAD-MSC for reasons such as failure to attend a scheduled appointment on time twice, absence without giving one working day’s prior notice, refusal to receive further treatment, failure to be contacted, failure to follow the treatment schedule, non-compliance with the recommended treatment plan/ dental advice, or having unreasonable expectations, etc.; and I understand that this is not an exclusive list, and the ultimate decision to discharge a patient rests with IAD-MSC;
  5. I understand that in the case of emergency, IAD-MSC may advise me / my child / the person concerned to seek further dental or medical attention or treatment elsewhere, which I will accept without any claim against IAD-MSC;
  6. I understand that I / my child / the person concerned have/ has to use the dental consumables, dental appliances or dental materials provided by IAD-MSC, and I shall have no claim against IAD-MSC due to any loss and damage arising from the inherent defects of such materials;

Fees and Charges

  1. I understand that there is no refund of Attendance Fee even if I / my child / the person concerned am / is not accepted as a teaching case or if I / my child / the person concerned am / is discharged by IAD-MSC;
  2. I agree to pay the fees and charges of IAD-MSC as prescribed in the Schedule of Fees which I understand may vary from time to time. I accept without any claim against IAD-MSC, that if I fail to settle the fees within the specified period, IAD-MSC has the absolute right to discharge me / my child / the person concerned from the care and attention provided at IAD-MSC; and
  3. I understand that I should not accept any demand notes or receipts issued by individual staff of IAD-MSC / the Faculty outside the invoicing system of IAD-MSC; and that all IAD-MSC fees and charges must be paid to IAD-MSC’s front desk directly, but not to any other staff.

就本人/本人子女/當事人* 在香港大學先進牙醫學研究所 – 專科診所(診所)的初步口腔檢驗及其後的牙科治療/會診(如適用),本人謹此(代表本人子女/當事人)聲明:

  1. 本人在登記前經已閱讀和充分瞭解「致求診市民通告」(2018.10之版本)及「收集求診者個人資料的聲明」;
  2. 本人同意及授權診所或香港大學/第三方使用為本人/本人子女/當事人所拍攝之所有或部份不含身份識別的照片、X光片、描影像或教學模型,作為教育、研究或發表用途;

診所功能

  1. 本人明白診所是一所教學診所,並不會提供公共牙科診療服務。教學病人的所有治療必須配合香港大學牙醫學院(牙醫學院)的專科學生、牙科輔助專業學生、及牙醫學院/診所職員之訓練課程;

初步口腔檢驗

  1. 本人/本人子女/當事人同意接受篩選過程中的口腔檢驗。本人明白如果本人/本人子女/當事人的個案在檢驗後未能被接受為教學用途,診所不會提供任何牙科治療或跟進。在此情況下,本人明白本人/本人子女/當事人須向其他執業牙醫或醫生尋求診治,並且不會因此向診所提出任何索償;
  2. 本人明白篩選及檢驗過程需時,亦沒有任何保證本人/本人子女/當事人會被接受為教學病人。本人明白,在篩選及檢驗過程期間,及被接受為教學病人之前,診所不會為本人/本人子女/當事人提供任何牙科治療或跟進。在此段期間如果出現任何癥狀或健康狀況,本人/本人子女/當事人應該及時向其他執業牙醫或醫生尋求診治,以避免因延誤求診而引致的健康風險;
  3. 本人知道初步口腔檢驗可能需時,一般需要整個上午或下午才完成;

其後的牙科治療/會診安排(如適用

  1. 假如本人/本人子女/當事人被接受為教學病人,本人明白所需輪候時間得視乎教學需要及牙患的類別及情況而定,為期由數星期至數年不等,而輪候期間本人/本人子女/當事人應該考慮向其他執業牙醫或醫生尋求診治,以避免因延誤求診而引致的健康風險;
  2. 本人明白由於涉及教學需要,每次治療/會診可能需時,一般需要整個上午或下午才完成;
  3. 本人明白如果診所認為本人/本人子女/當事人的牙患已不適合教學用途或無須再經本院其他診室作進一步診斷,診所絕對有權終止提供進一步的治療或跟進。在此情況下,本人明白本人/本人子女/當事人須向其他執業牙醫或醫生尋求診治,並且不會就此向診所提出任何索償;
  4. 本人接受如果本人/本人子女/當事人兩次未能準時赴約、缺席而未在一個工作日前向診所作出改期通知、拒絕接受進一步治療、無法被聯絡、未能配合所編排之診治時間、拒絕配合既定治療計劃或建議、或有不合理期望等,診所有絕對決定權終止本人/本人子女/當事人於診所所接受的治療及診症,本人不會就此向診所提出任何索償。本人明白這聲明書所列未完全概括診所可能終止替本人/本人子女/當事人治療之原因,而且診所擁有終止病人治療之最終決定權;
  5. 本人明白當遇上緊急情況時,診所可能建議本人/本人子女/當事人向其他執業牙醫或醫生尋求診治,本人將會接受此安排,並且不會向診所提出任何索償;
  6. 本人明白本人/本人子女/當事人須使用由診所供應之牙科消耗物、牙具及牙科物料,本人不會就因該等物料的品質問題而引起的任何損失或損害向診所提出任何索償;

費用

  1. 本人明白即使本人/本人子女/當事人未能被接受為教學用途或本人/本人子女/當事人的治療被診所終止,診症費是不會獲得退還;
  2. 本人同意根據診所收費表繳付診所費用,亦明白所有收費可隨時作出調整。本人明白如果本人未能在指定的期限內繳付有關費用,診所有絕對決定權終止本人/本人子女/當事人於診所所接受的進一步治療及診症,本人不會就此向診所提出任何索償;及
  3. 本人明白除經診所帳單系統所開發的帳單或收據外,本人不應該接受任何由個別診所/牙醫學院職員所發出的帳單或收據;以及所有診所費用須直接向診所前台繳交,而不會向其他職員繳費。