• Patient Information

  • Format: (000) 000-0000.

  • Client Consent Form For Collection, Use And Disclosure Of Personal Information

  • Privacy of your personal information is an important part of providing you with quality preventive dental hygiene care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly.  We also try to be open and transparent as possible about the ways we handle your personal information. It is important for us to provide this service to our clients.


    Our Privacy Information Officer is Nancy-Jo Demers, RDH/Owner/Operator


    All staff that comes in contact with your personal information are all aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.


    Our detailed Privacy Policy outlines what our office is doing to ensure that:

    • Only necessary information is collected about you
    • We only share your information with your consent
    • Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols.
    • Our privacy protocols comply with privacy legislation, standards of our provincial regulatory bodies (The College of Dental Hygienists of Ontario) and the law.

  • Client Consent

  • I know that Expressions has a Privacy Policy, and I can ask to see the written Policy at any time.

    I approve that Expressions Dental Hygiene Clinic can collect and disclose personal
    information about         as set out in the information about
    the clinic’s privacy policy.

  • Client Information and Consent Form for Whitening

  • Expectations

  • People with healthy teeth and gums but who have stains or yellowish tints seem to get the best results. On some occasions, you may feel a little tingling or perhaps a slight sensitivity. Teeth and /or gums may be sensitive for a short time after treatment. You may see temporary blanching to the gums (white gums) but this is normal and will disappear, usually within less than a day. Your teeth will never be whiter than your genetic traits. All teeth bleach differently. Possible white spots or demineralization may appear on patients who have had braces or who have porous enamel, but this will disappear within 24 hours. This treatment will not whiten or damage veneers, crowns, white fillings and or false teeth. There are no guarantees.

  • Rows

  • Aftercare and Follow-up

  • For a minimum of 24 hours after the process, please avoid smoking, consuming coffee, tea, dark-colored soda, red wine, curry, beetroot, and any other food or drink that would stain the teeth.  If your teeth are sensitive you can use Sensodyne toothpaste for relief. There is no guarantee as to the longevity of results. Therefore for optimal results, we recommend touching up your smile every 6- 12 months for best maintenance.

  • Release

  • CAUTION: Use it at your own risk. Consenting to treatment frees all distributors, manufacturers, and affiliates from all liability associated with the use of this system. A proper assessment ensures your suitability for tooth whitening however in the event recommendations are made by the hygienist prior to whitening it is your responsibility to ensure this is carried out. If you have any adverse reaction to this or any whitening product terminate treatment and consult your health professional.

  • IN CONSIDERATION of teeth whitening products supplied by Expressions and trademarked Bright White, I         , hereby release and forever discharge Expressions and its agents, representatives, dealers, employees, directors, officers, shareholder, successors, and assigns from any and all actions, causes of action, claims and demands for damages, loss or injury, however arising which may be sustained by me as a result of using the tooth whitening products supplied by Expressions.

  • Laser Treatment for Aphthous Ulcers and Herpetic Lesions (Cold Sores)

  • We are constantly striving to improve the standard of care that we provide to our clients in our dental practice and with this in mind we are proud and excited to introduce to our practice this unique treatment. Oral aphthous ulcers, and cold sores that appear on the lip/border of lip area can be extremely uncomfortable or painful. Treatment with the laser can help reduce pain and shorten the healing time. For the best results, treating lesions within their 48 hours of appearance, or in the case of a cold sore, during the prodromal or "tingling stage" is ideal.

    Laser treatment for oral lesions provides the following benefits to you:

    • Reduced pain - The laser immediately provides a temporary anesthetic effect to the area of discomfort that usually lasts about 1/2 hour, and typically reduced discomfort afterward.
    • The duration of the lesion will be much shorter and healing much quicker.
    • The chances of a lesion re-appearing in the same location is extremely rare!

    Keep in mind herpetic lesions (cold sores) are highly contagious, and we cannot see you for regular treatment while the lesion is in the vesicle stage.

    What to expect:

    • During the treatment with the laser you may experience a gentle warmth, but no soreness.
    • The laser treatment is performed without touching the lesion.
    • Fast, easy, and painless.

  • The cost for treatment of oral lesions is $      
    This may or may not be covered by your dental plan.

  • Laser Bacterial Reduction

  • We are constantly striving to improve the standard of care that we provide to our clients in our dental practice and with this in mind we are proud and excited to introduce to our practice the clinically proven technique of Laser Bacterial Reduction.

  • Laser therapy provides the following benefits to you;

    • Faster healing
    • Less discomfort
    • Low-level laser energy kills the bacteria that create the infection
    • Delayed bacterial formation after your professional cleaning
    • Better treatment outcomes using a non-surgical approach

    Periodontal disease (also known as gum disease) can affect up to 80% of adults and is often silent until it is in advanced stages. The medical and dental community are now altered to the fact that there is strong evidence linking those with gum disease to being at greater risk for heart disease, lung disease, certain cancers, osteoporosis (bone loss), strokes, Alzheimer's, and diabetes.

    This knowledge has given us strong reason to not only mechanically remove the bacteria and deposits during your professional cleaning but also to additionally address the underlying infection and 'hard to reach 'bacteria that cause gum disease in the 1st place. The Laser is painless, takes approximately 5-8 minutes, and producers no adverse side effects. Commitment to regular preventive hygiene visits and daily self-care is integral to ensuring you achieve the best possible treatment outcome from the laser.

  • The cost for Laser Bacterial Reduction is $      . If you have any further questions do not hesitate to ask your dental hygienist about this treatment. We will be more than happy to answer any of your questions. Please provide consent to this service by signing below.

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