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Setup
Within your WinOMScs Software, please complete the following steps to connect your truForm account within your PMS.
In order to complete this section, you must complete the below item:
Once this 1 item above is completed, please follow the instructions below.
Adding Integration Credentials v9.2 (or higher)
Please follow the instructions below to add your truForm created credentials into your WinOMScs Software. This will connect your practice software to your MySecurePractice truForm account, enabling you to pull submitted truForms into your software!!
- Once you've created your Generated Credentials *required step!
- Within WinOMScs, select the Tables drop down:
- Select the Practice option:
- Select the Patient Registration Preferences option
- In the V6 Log On Credentials section, enter the User ID and Password generated credentials created from: https://mysecurepractice.com.
**When Practice Log On is selected, you are setting preferences for the practice. When Office Log On is selected, the offices are displayed in the list, and you can select the office for which you are setting preferences.
- In the Select Pages to Visit section, the checkbox is selected for each page in the Process Patient Registration wizard that will display when you are downloading patient information. If there are windows you want to skip during the process, deselect the checkbox next to those windows.
- In the Default Finish Option section, select which window you want to display when you have finished importing the patient information.
- Select the OK button to save your changes.
Now you can poll your v.6 MySecurePractice submissions!
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Overview
The below steps will walk you through integrating your truForm within WinOMScs.
In order to complete this section, you must complete the below items:
- Generate Credentials through MySecurePractice (one time setup)
- Add MySecurePractice Generated Credentials into WinOMScs Software (one time setup)
- If truForm doctor signatures are turned ON, you MUST sign through MySecurePractice FIRST (for each truForm submission)
Once the 3 items above are completed, please follow the instructions below:
PATIENT REGISTRATION INTEGRATION
- Within WinOMScs, select the icon: on the WinOMS toolbar
- The Pre-Registered Patients Queue window will open below:
- A list below will provide truForm submission patient First and Last Names (of forms that need to be integrated):
The Pre-Registered Patients Queue displays all the patients whose information has been downloaded but not yet processed. To search for a particular patient, or to narrow down the list by office, use the fields in the Filter Criteria section, and click Filter. You can also click the column headings to sort.
- Click directly on the patient you would like to integrate within the list, and select the Convert button:
- **If you do not see the submitted patient truForm, you may have doctor signatures turned on.
- Under the Process Patient Registration window, the Potential Matches section will display a list of any existing Patient accounts that match either the last name or DOB of the patient:
- Click directly on the patient you would like to integrate, and select an option under the Next Action section:
- Discard Registration Item: You can select this option if you do NOT want to integrate this patient truForm, then select the Next button and the window will close for you.
- Merge Registration with Existing Patient/Walk-in: Once the correct patient is selected under Potential Matches, select this option if you would like to merge the truForm data into the patients existing account. This will walk you through a wizard to review and verify all data being merged into the patient account.
- Create a New Patient Account: You can select this option to create a brand new account within WinOMscs. This will walk you through a wizard to review and verify all the data being added to the patient account.
- Once you've selected the correct option under Next Action, select the Next button to continue:
MERGE REGISTRATION WITH EXISTING PATIENT/WALK-IN
If you select the Merge Registration with Existing Patient/Walk-in option, a wizard will walk your practice through the following screens to complete integration of the patient's submitted truForm:
Patient Demographics Section (Existing Patient Account)
- To begin converting pre-registration data into a patient account. this is the first screen you will see:
Patient Registration Details/Left Side
Patient Account - Demographics/Right Side Reflects what the patient has submitted on their truForm. Reflects the patient account with merged information, which is editable.
- If you would like to update the left hand side information to the patient's account, select the forward button:
- Select the option you would like:
- With either option above, a pop-up will ask you to confirm this action. Select the Yes button:
Update All Fields on Right selection:
Update Empty Fields on Right selection:
- If you would like to update the left hand side information to the patient's account, select the forward button:
- Select a Default Office & Provider (if not already completed):
- Once everything is set, select the Next button to continue on to the Guarantor section:
Guarantor Section (Existing Patient Account)
- If the Relationship is Self, then the Use Patient option will be selected:
- If the relationship is someone else, select the Search for Guarantor option to search your database for that person.
- If the guarantor is not in the system, select the Create new Guarantor option and enter the guarantor's information in the appropriate fields.
- If the relationship is someone else, you can select the Relationship (anything other than SELF), and select the forward button located in the middle to copy over some or all of that information submitted on truForm:
- Under Billing Information, select a Billing Category and Fee Schedule for the patient (if not done already)
- Select the billing options you want to apply to this patient to the right: Send Statement, Apply Service Charge, Print Dunning Message, or In Collections:
- Select the billing options you want to apply to this patient to the right: Send Statement, Apply Service Charge, Print Dunning Message, or In Collections:
- Once you are finished on this page, select the Next button to continue onto the Employer section: 17
Employer Section (Existing Patient Account)
- If the patient is unemployed, No Employer is selected.
- Select the forward button located in the middle to copy over some or all of that information submitted on truForm:
- Select Search for Employer if the employer might be in your database, or select Create New Employer and enter the employer's information in the appropriate fields
- Once you are finished on this page, select the Next button to continue onto the School Section:
School Section (Existing Patient Account)
- If the patient is not a student, No School is selected.
- Select the forward button located in the middle to copy over some or all of that information submitted on truForm:
- If the patient is a student, select Search for School or Create New School and enter the school's information
- Once you are finished on this page, select the Next button to continue onto the Dental Insurance Section:
Dental Insurance Section (Existing Patient Account)
The Dental Insurance window of the wizard are displayed with the Patient Registration Details on the left side and the editable fields on the right.
To Validate or Edit insurance information on the Dental Insurance window:- Click the in the left pane to view details of the patient's insured party, employer and insurance carriers.
- In the right pane, select Search for Insured, Use Patient, or Use Guarantor
- To search, enter the name and click
- To add a new insured party, click .
- The Insured Party Setup window is displayed.
- Select Search for Employer, Use Patient, or no Employer.
- To search, enter the employer name and click .
- To add a new employer, click .
- The Employer Data Entry window is displayed.
- Under Search for Plan, enter the insurance plan name and click .
- To add a new insurance plan, click .
- The Plan Data Entry window is displayed.
- Enter the policy information in the Policy Details section
- Once you are finished on this page, select the Next button to continue onto the Medical Insurance Section:
Medical Insurance Section (Existing Patient Account)
The Medical Insurance window of the wizard are displayed with the Patient Registration Details on the left side and the editable fields on the right.
To Validate or Edit insurance information on the Medical Insurance window:- Click the arrows in the left pane to view details of the patient's insured party, employer and insurance carriers.
- In the right pane, select Search for Insured, Use Patient, or Use Guarantor
- To search, enter the name and click
- To add a new insured party, click .
- The Insured Party Setup window is displayed.
- Select Search for Employer, Use Patient, or no Employer.
- To search, enter the employer name and click .
- To add a new employer, click .
- The Employer Data Entry window is displayed.
- Under Search for Plan, enter the insurance plan name and click .
- To add a new insurance plan, click .
- The Plan Data Entry window is displayed.
- Enter the policy information in the Policy Details section
- Once you are finished on this page, select the Next button to continue onto the Health History Section:
Health History Section (Existing Patient Account)
- Double-click an item in the Health History Item list on the left. Depending on the type of item, the Add Medical History, Add Allergies, or Add Medications window is displayed with that item in the Description field.
- Click Ok. The item is added to the Attach(ed) to Patient Chart list on the right, and a check mark is displayed next to that item in the Health History Item list.
- Repeat for each history item you want to attach to the patient's record
- Once you are finished on this page, select the Next button to continue onto the Referral Section:
Referral Section (Existing Patient Account)
- Click the search button, to the right of the text field for the Primary Referral
- The Referral Source Search window will appear.
- If this doctor is already in your database: Select the name and click the Ok button.
- If no records match the search criteria: Click New to access the Referral Source Data Entry window. Enter the doctor's information and click Ok.
- Repeat for each doctor the patient has listed as a referral
- To skip the referral information, use the drop-down list to select None in the Type field next to each doctor
- Click Next to continue onto the Summary Section.
Summary Section (Existing Patient Account)
This will give you an overview of the modification made to this patient's account.
- Review of summary entries for each window completed in the wizard
- If you select the More Detail option, this will display more detailed information about the summary.
- To return to a previous window to make changes, you can click the Go To button and select the window you want, and then return to the Summary window.
- Under Finish Options, select one of the following:
- Patient Activity (to go to the Patient Workspace window for this patient.)
- Registration Queue (to return to the Registration Queue)
- Close Wizard (to exit this process)
- Select the Finish button:
CREATE A NEW PATIENT ACCOUNT
If you select the Create a New Patient Account option, a wizard will walk your practice through the following screens to complete integration of the patient's submitted truForm:
- Patient Demographics
- Guarantor
- Employer
- School
- Dental Insurance
- Medical Insurance
- Health History
- Referral
- Summary
Patient Demographics Section
To begin converting pre-registration data into a patient account. this is the first screen you will see:
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- Select a Default Office & Provider:
- Once you are finished on this page, select the Next button to continue on to the Guarantor section:
Guarantor Section
- If the Relationship is Self, then the Use Patient option will be selected:
- If the relationship is someone else, select the Search for Guarantor option to search your database for that person.
- If the guarantor is not in the system, select the Create new Guarantor option and enter the guarantor's information in the appropriate fields.
- Under Billing Information, select a Billing Category and Fee Schedule for the patient (if not done already)
- Select the billing options you want to apply to this patient to the right: Send Statement, Apply Service Charge, Print Dunning Message, or In Collections:
- Select the billing options you want to apply to this patient to the right: Send Statement, Apply Service Charge, Print Dunning Message, or In Collections:
- Once you are finished on this page, select the Next button to continue onto the Employer section:
Employer Section
- If the patient is unemployed, No Employer is selected.
- Select Search for Employer if the employer might be in your database, or select Create New Employer and enter the employer's information in the appropriate fields
- Once you are finished on this page, select the Next button to continue onto the School Section:
School Section
- If the patient is not a student, No School is selected.
- If the patient is a student, select Search for School or Create New School and enter the school's information
- Once you are finished on this page, select the Next button to continue onto the Dental Insurance Section:
Dental Insurance Section
The Dental Insurance window of the wizard are displayed with the Patient Registration Details on the left side and the editable fields on the right.
To Validate or Edit insurance information on the Dental Insurance window:- Click the in the left pane to view details of the patient's insured party, employer and insurance carriers.
- In the right pane, select Search for Insured, Use Patient, or Use Guarantor
- To search, enter the name and click
- To add a new insured party, click .
- The Insured Party Setup window is displayed.
- Select Search for Employer, Use Patient, or no Employer.
- To search, enter the employer name and click .
- To add a new employer, click .
- The Employer Data Entry window is displayed.
- Under Search for Plan, enter the insurance plan name and click .
- To add a new insurance plan, click .
- The Plan Data Entry window is displayed.
- Enter the policy information in the Policy Details section
- Once you are finished on this page, select the Next button to continue onto the Medical Insurance Section:
Medical Insurance Section
The Medical Insurance window of the wizard are displayed with the Patient Registration Details on the left side and the editable fields on the right.
To Validate or Edit insurance information on the Medical Insurance window:- Click the arrows in the left pane to view details of the patient's insured party, employer and insurance carriers.
- In the right pane, select Search for Insured, Use Patient, or Use Guarantor
- To search, enter the name and click
- To add a new insured party, click .
- The Insured Party Setup window is displayed.
- Select Search for Employer, Use Patient, or no Employer.
- To search, enter the employer name and click .
- To add a new employer, click .
- The Employer Data Entry window is displayed.
- Under Search for Plan, enter the insurance plan name and click .
- To add a new insurance plan, click .
- The Plan Data Entry window is displayed.
- Enter the policy information in the Policy Details section
- Once you are finished on this page, select the Next button to continue onto the Health History Section:
Health History Section
- Double-click an item in the Health History Item list on the left. Depending on the type of item, the Add Medical History, Add Allergies, or Add Medications window is displayed with that item in the Description field.
- Click Ok. The item is added to the Attach(ed) to Patient Chart list on the right, and a check mark is displayed next to that item in the Health History Item list.
- Repeat for each history item you want to attach to the patient's record
- Once you are finished on this page, select the Next button to continue onto the Referral Section:
Referral Section
- Click the search button, to the right of the text field for the Primary Referral
- The Referral Source Search window will appear.
- If this doctor is already in your database: Select the name and click the Ok button.
- If no records match the search criteria: Click New to access the Referral Source Data Entry window. Enter the doctor's information and click Ok.
- Repeat for each doctor the patient has listed as a referral
- To skip the referral information, use the drop-down list to select None in the Type field next to each doctor
- Click Next to continue onto the Summary Section.
Summary Section
This will give you an overview of the modification made to this patient's account.
- Review of summary entries for each window completed in the wizard
- If you select the More Detail option, this will display more detailed information about the summary.
- To return to a previous window to make changes, you can click the Go To button and select the window you want, and then return to the Summary window.
- Under Finish Options, select one of the following:
- Patient Activity (to go to the Patient Workspace window for this patient.)
- Registration Queue (to return to the Registration Queue)
- Close Wizard (to exit this process)
- Select the Finish button:
DOCTOR REFERRAL INTEGRATION
If you have a referral form setup for integration, please use these instructions as a reference to what you will see when you integrate a referral form first! Although WinOMScs is only setup to take in Patient Registrations, we can send over your submitted referral forms in the same exact way.
- Follow the integration steps above
- Once integration is complete, if you view the submitted Referral Truform within the patients account- note the important information below:
- The referral form will be labeled as Patient Registration Form- WinOMScs is only designed to integrate the patient registration, although we can allow the referral form to integrate- it will remain incorrectly labeled within WinOMScs!
- Also, if the referring doctor submitted any common file type attachments with this truForm, you will see them embedded within the submitted PDF here.
- The referral form will be labeled as Patient Registration Form- WinOMScs is only designed to integrate the patient registration, although we can allow the referral form to integrate- it will remain incorrectly labeled within WinOMScs!
- Once you are ready to integrate the patient registration submitted by the patient- follow these instructions here.
- Once you fully integrate both the referral and registration truForm, the Patient Reg section will look similar to the below example:
- You can click on each line item to see either the patient registration or the referral form
- One easy way to identify the referral form is by date within WinOMScs, the referral form should be an older date than the registration form.
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Mapping
Free typed Medication and Allergies will not directly integrate, but you can map these items for each submission. Please see below for step by step instructions.
In order to complete this section, you must complete the below items:
- Generate Credentials for WinOMScs Software through MySecurePractice
- Add MySecurePractice Generated Credentials into WinOMScs Software
- **If truForm doctor signatures are turned ON, you MUST sign through MySecurePractice FIRST
Once the 3 items above are completed, please follow the instructions below:
Note this section will not automatically integrate, you can manually map each item through your WinOMScs software. Follow the instructions below, to complete this.
For your medication Free Type List, usually asked in the form of this question seen below. Patients can manually write out there medication names used (or select from a Lexi Comp pick list of medications):
Are you taking any kind of medication, drug, pills? (if YES, they would list them)...
- The free type list of medications does not automatically integrate within your software like the health history items will.
- The free typed medication area entered within TruForm will come over within the WinOMScs software under Other Medications
- The free type list of medications can be added as a medical alert, please note the following:
- WinOMScs does not recommend this unless it is something specific, like allergic reactions or a serious medical condition.
- With the free type medication area, you can retype whatever the patient completed and add as a alert. Please call WinOMScs for further help with this.
In this section, we will go over the following:
MAPPING A NEW MEDICATION NOT IN YOUR DATABASE
Medications manually entered by patient via truform will automatically show under Other Medications within WinOMScs below
- Select and Copy the first medication under Other Medications below:
Hint: You can copy this medication by highlighting the entire medication, then while highlighted select the keyboard shortcuts for CTRL + C (at the same time) to copy this to your computers clipboard. - Select the Medication radio button option located at the top:
- Select the button, located to the right of the Description text field:
- Under Description text field, enter the medication name (in this case we are using Advil Cold & Sinus)
Hint: You can paste this previously copied medication by adding your cursor in the Description text field, now select the keyboard shortcuts for CTRL + V (at the same time) to paste your previously copied medication here. - Select the Find button:
**if you do see a match to your LEFT- select here to continue.
- If you don't see a match within the list to the LEFT, select the New button:
- Enter the Medication Name under Description text field:
Hint: You can paste this previously copied medication by adding your cursor in the Description text field, now select the keyboard shortcuts for CTRL + V (at the same time) to paste your previously copied medication here.
- Select the button, located to the RIGHT of the Lexicomp Drug ID text field (this will link this to a Lexicomp Drug ID):
- Enter the description (name of drug listed)- in this case we are using Advil Cold & Sinus and select the Find button below:
Hint: You can paste this previously copied medication by adding your cursor in the Description text field, now select the keyboard shortcuts for CTRL + V (at the same time) to paste your previously copied medication here. - Select the medication name to the left and select the Ok button:
- Select Ok again, once you are ready to map this medication:
- Under Attach(ed) to Patient Chart you should now see the new medication has been added:
Repeat steps 1-12 above to add any new medications to your WinOMScs software!
MAPPING AN EXISTING MEDICATION ALREADY IN YOUR DATABASE
Once the medication is pulled into the software, you will see the medications typed in the above form within the Other Medications.
- Select and Copy the first medication under Other Medications below:
Hint: You can copy this medication by highlighting the entire medication, then while highlighted select the keyboard shortcuts for CTRL + C (at the same time) to copy this to your computers clipboard. - Select the Medication option located at the top
- Select the button, located to the right of the Description text field:
- Enter the Medication Name under Description text field (in this case we are using Benadryl Children)
Hint: You can paste this previously copied medication by adding your cursor in the Description text field, now select the keyboard shortcuts for CTRL + V (at the same time) to paste your previously copied medication here. - Select the Find button:
- If the medication was entered previously, you will see a match in your list to the LEFT.
- Click directly on the medication, and select the Ok button:
- Under Attach(ed) to Patient Chart, you should now see the new medication has been added!
Repeat steps 1-8 to add any existing medications to your WinOMScs software!
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PDF
This article will walk you through how to view the submitted patient truForm through your patient record within WinOMScs.
In order to complete this section, you must complete the below items:
- Generate Credentials for WinOMScs Software through MySecurePractice
- Add MySecurePractice Generated Credentials into WinOMScs Software
- **If truForm doctor signatures are turned ON, you MUST sign through MySecurePractice FIRST
Once the 3 items above are completed, please follow the instructions below:
Within WinOMScs, we integrate the data from the truForm as well as the submitted PDF TruForm right into your WinOMScs patient's account. Please follow these instructions to view the submitted form at anytime!
- Locate and open the patients account
- Select the Patient Reg option, located on the left hand column
- Any integrated truForm will be listed as Patient Registration Form (even if you integrate a referral form or consent form, the label will always be Patient Registration Form).
- The date will indicate when it was integrated
- Click on the form name (Patient Registration Form) to view the submitted truForm directly below:
*NOTE, if the patient uploaded any (common file) attachments when submitting this form, you can scroll down to view those documents embedded within this submitted form.
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Fields
This includes ALL fields that integrate between truForm and WinOMScs. If your custom form is setup correctly, items below will populate within your software. Note, if you have additional fields that are NOT listed below, you can manual enter them into your patients account once integration is completed!
Overview
If you use our standard form below, the sections listed below are already integrated!
Anything below labeled with DOES NOT INTEGRATE, is a field that exists on our standard form above, but does not automatically integrate on either standard or custom.
Field Count: 296 total truForm fields integrate into your PMS!
Patient Info
*IF YOU ARE USING A CUSTOM FORM:
- Patient Name on the form must be split out into first name last name in order to integrate correctly.
- Patient Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly.
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Dentist/Doctor/Referred By/Nearest Relative Names on the form must be split out into first name last name in order to integrate correctly.
- Prefix
- First Name
- Middle Initial
- Last Name
- Suffix
- Nickname
- Gender
- Martial Description
- Date of Birth
- Age
- Social Security Number
- Home Phone
- Work Phone
- Work Ext.
- Cell Phone
- Address Street Name
- Apt
- City
- State or Province
- Zip or Postal Code
- Employer Name
- Driver’s License
- Patient former patient?
- Dentist First Name
- Dentist Last Name
- Doctor First Name
- Doctor Last Name
- Referred By First Name
- Referred By Last Name
- Nearest Relative First Name
- Nearest Relative Last Name
- Nearest Relative Phone
- Payment Method
DOES NOT INTEGRATE:
- Orthodontist First Name
- Orthodontist Last Name
- Preferred Pharmacy
- Pharmacy Tel.
Emergency Name must be one field (can't be split into first name last name fields, or else it will not integrate).
- Emergency Full Name
- Home Phone
- Work Phone
DOES NOT INTEGRATE:
- Emergency contact relation
Responsible Party Info
*IF YOU ARE USING A CUSTOM FORM:
- Responsible Name on the form must be split out into first name last name in order to integrate correctly.
- Patient Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly.
- Prefix
- First Name
- Last Name
- Suffix
- Relationship to Patient
- Social Security Number
- Date of Birth
- Address Street Name
- Address Street Name 2
- City
- State or Province
- Zip or Postal Code
- Employer Name
- Home Phone
- Work Phone
DOES NOT INTEGRATE:
- Age
- Middle Initial
- Email Address
Spouse/Other Guarantor Info
- This entire section will not integrate
School/Insurance Info
*IF YOU ARE USING A CUSTOM FORM: School Name/ Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly. - School Name
- School Address Street Name
- School Address Street Name 2
- School City
- School State or Province
- School Zip or Postal Code
- School Phone
- School Status (Full, Part, Not)
- Employer Status(Full, Part, Not)
- PPO or HMO
Insurance Info
*IF YOU ARE USING A CUSTOM FORM:
- Each insurance type (primary medical, primary dental, secondary medical, secondary dental must be separated into its own area for each question below in order to integrate correctly.
- All Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly.
- Insured Name on the form must be split out into first name last name in order to integrate correctly.
PRIMARY DENTAL
- Insured Relation to Patient
- Insured Prefix
- Insured First Name
- Insured Middle Initial
- Insured Last Name
- Insured Suffix
- Insured Gender
- Insured Date of Birth
- Insured Social Security Number
- Insured Home Phone
- Insured Home Address Street
- Insured Home Address Street 2
- Insured City
- Insured State or Province
- Insured Zip Code or Postal Code
- Insured Employer Name
- Insured Employer Address
- Insured Employer Address 2
- Insured Employer City
- Insured Employer State or Province
- Insured Employer Zip or Postal
- Insured Employer Phone Number
- Insured Policy Group Name
- Insured Policy Group Number
- Insured Policy ID
- Insured Policy Plan
- Insured Insurance Company Name
- Insured Insurance Address Street
- Insured Insurance Address Street 2
- Insured Insurance City
- Insured Insurance State or Province
- Insured Insurance Zip or Postal Code
- Insured Insurance Phone Number
SECONDARY DENTAL
- Insured Relation to Patient
- Insured Prefix
- Insured First Name
- Insured Middle Initial
- Insured Last Name
- Insured Suffix
- Insured Gender
- Insured Date of Birth
- Insured Social Security Number
- Insured Home Phone
- Insured Home Address Street
- Insured Home Address Street 2
- Insured City
- Insured State or Province
- Insured Zip Code or Postal Code
- Insured Employer Name
- Insured Employer Address
- Insured Employer Address 2
- Insured Employer City
- Insured Employer State or Province
- Insured Employer Zip or Postal
- Insured Employer Phone Number
- Insured Policy Group Name
- Insured Policy Group Number
- Insured Policy ID
- Insured Policy Plan
- Insured Insurance Company Name
- Insured Insurance Address Street
- Insured Insurance Address Street 2
- Insured Insurance City
- Insured Insurance State or Province
- Insured Insurance Zip or Postal Code
- Insured Insurance Phone Number
PRIMARY MEDICAL
- Insured Relation to Patient
- Insured Prefix
- Insured First Name
- Insured Middle Initial
- Insured Last Name
- Insured Suffix
- Insured Gender
- Insured Date of Birth
- Insured Social Security Number
- Insured Home Phone
- Insured Home Address Street
- Insured Home Address Street 2
- Insured City
- Insured State or Province
- Insured Zip Code or Postal Code
- Insured Employer Name
- Insured Employer Address
- Insured Employer Address 2
- Insured Employer City
- Insured Employer State or Province
- Insured Employer Zip or Postal
- Insured Employer Phone Number
- Insured Policy Group Name
- Insured Policy Group Number
- Insured Policy ID
- Insured Policy Plan
- Insured Insurance Company Name
- Insured Insurance Address Street
- Insured Insurance Address Street 2
- Insured Insurance City
- Insured Insurance State or Province
- Insured Insurance Zip or Postal Code
- Insured Insurance Phone Number
SECONDARY DENTAL
- Insured Relation to Patient
- Insured Prefix
- Insured First Name
- Insured Middle Initial
- Insured Last Name
- Insured Suffix
- Insured Gender
- Insured Date of Birth
- Insured Social Security Number
- Insured Home Phone
- Insured Home Address Street
- Insured Home Address Street 2
- Insured City
- Insured State or Province
- Insured Zip Code or Postal Code
- Insured Employer Name
- Insured Employer Address
- Insured Employer Address 2
- Insured Employer City
- Insured Employer State or Province
- Insured Employer Zip or Postal
- Insured Employer Phone Number
- Insured Policy Group Name
- Insured Policy Group Number
- Insured Policy ID
- Insured Policy Plan
- Insured Insurance Company Name
- Insured Insurance Address Street
- Insured Insurance Address Street 2
- Insured Insurance City
- Insured Insurance State or Province
- Insured Insurance Zip or Postal Code
- Insured Insurance Phone Number
Health History
*IF YOU ARE USING A CUSTOM FORM: If you have a group of problems/issues in one question- they will not integrate. They must be laid out similar to the format given below.
Some items we group together, will come over as one item, see below:
- Reason for today's office visit
- Are you in good health
- Weight
- Height
- Have there been any changes in your general health in the past year
- Are you under the care of a physician
- If so, for what are you being treated
- Date of last visit
- Have you had any illness, operation or been hospitalized in the past five years
- If so, describe
- Do you have unhealed / recurrent injuries or inflamed areas, growths or sore spots in or around your mouth
- If so, describe where
- Do you have a prosthetic joint / implant
- If so, describe where
- Have you had a heart valve replacement or vascular graft
- Rheumatic fever
- Damaged heart valves / mitral valve prolapse
- Heart murmur
- High blood pressure
- Low blood pressure
- Chest pain / angina
*Comes over as angina - Heart attack(s)
- Irregular heart beat
- Cardiac pacemaker
- Heart surgery
- Pneumonia, bronchitis, chronic cough
*Comes over as bronchitis/chronic cough - Asthma
- Hay fever / sinus problems
- Snoring
- Sleep apnea / CPAP
- Difficult breathing / other lung trouble
*Comes over as other lung trouble - Tuberculosis
- Emphysema
- Do you smoke or vape
- Do you use chewing tobacco
- Blood transfusion
- Blood disorder such as anemia
*Comes over as anemia - Bruise easily
- Bleeding tendency / abnormal bleed
*Comes over as bleeding tendency - Hepatitis, jaundice, or liver disease
- Infectious mononucleosis
- Gallbladder trouble
- Fainting spells
- Convulsions / epilepsy
- Stroke
- Thyroid trouble
- Diabetes
- Low blood sugar
- Kidney trouble
- Are you on dialysis
- Swollen ankles / arthritis / joint disease
*Comes over as arthritis - Stomach ulcers / acid reflux
*Comes over as stomach ulcers - Contagious diseases
- Sexually transmitted diseases
- Problems with immune system
Possibly from medication / surgery, etc. - Delay in healing
- A tumor or growth
- Cancer / radiation therapy / chemotherapy
*Comes over as xray or chemo - Chronic fatigue / night sweats
- Are you on a diet
- A history of alcohol abuse and / or treatment for alcohol abuse
- A history of marijuana or illegal drug use
- Contact lenses
- Eye disease / glaucoma
- Mental health problems / anxiety / depression
*Comes over as mental health problems - A removable dental appliance
- Pain or clicking of jaws when eating
DOES NOT INTEGRATE:
- Have you ever had general anesthesia
- Have you, or a family member, had any unusual or serious reactions to general anesthesia
- Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment
- If so, how much a day do you smoke/vape
- High cholesterol
- Alcohol intake?
- If so, drinks per Day
- If so, drinks per Week
- Osteoporosis / osteopenia
- Osteonecrosis
- COVID-19
- Autoimmune disease
Women Only
- Is there a possibility of pregnancy
- Expected delivery date
- Are you nursing
- Are you taking birth control pills
Medications
- Any kind of medication, drug, pills
- Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Xarelto, Eliquis, Fish oil)
- Have you ever taken diet pills
- Any natural product, herbal supplement or homeopathic remedy
- Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis. If so, please list:
DOES NOT INTEGRATE:
- Are you taking, or have you ever taken, bone density meds. RANKL inhibitors or bisphosphonates such as Prolia, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, Xgeva, or Evista in the past 12 years
- If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:
- Other
- Treating Doctor Name
- Please list any medications you are currently taking:
**Please note each medication they free type will come over as either a ALERT or a PROGRESS NOTE, from here you will have to click the green plus sign to add/retype or copy each medication manually within your patients chart in WinOMScs. (1-20 medications)
Allergies
- Local anesthetic (numbing meds.)
- Penicillin
- Other antibiotics
- Sulfa drugs
- Sodium pentothal / Valium /other tranquilizers
- Aspirin
- Codeine or other narcotics
- Latex
- Soy
- Eggs / yolk
- Sulfites
- Please list any other medication or antibiotic you are allergic to:
- Medication/Antibiotic #1
- Medication/Antibiotic #2
- Medication/Antibiotic #3
- Medication/Antibiotic #4
- Medication/Antibiotic #5
- Medication/Antibiotic #6
- Medication/Antibiotic #7
- Medication/Antibiotic #8
- Medication/Antibiotic #9
- Medication/Antibiotic #10
DOES NOT INTEGRATE:
- Amoxicillin
- Do you have any known allergies
- Please list any allergies other than drug allergies:
Family History
- Family History of Cancer
- Family History of Diabetes
- Family History of Heart Disease
- Family History of Anesthetic Problems
Injury Info
- Date of injury
- Type of accident- auto/work/other
- Insurance Company Handling Claim
- Claim Number
- Attorney or Adjustor
- Attorney Phone
Personal Info
- Is there any condition concerning your health that the Doctor should be told about
- If Yes, why
- Do you wish to speak to the Dr. privately about anything
-
Support
You can contact WinOMScs Support below (FOR EXISTING WinOMScs CLIENTS)
Phone: 800-275-4637 Hours: M-F 8am - 8:30pm EST Email: oralsurgerysupport@csdental.com Support Page
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