• Patient Medical / Dental History Information

  • Gender*
  • Do you have an email?*

  • Responsible Party*
  • Does the patient has any siblings (under 18 years) accompanying for the same appointment?
  • Do you have any kids (under 18 years old) accompanying you for the same appointment?
  • Are you a new patient?*
  • Current Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Responsible Party's Information

  • Relation to the patient*

  • Existing Patient

  • If there is change in any of the following, please check the box*

  • Phone Number

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Medical Update

  • Is there any change in the Family Physician?
  • Is there any update in your medication?
  • Is there any update in your allergies?
  • Is there any update in your medical conditions?
  • Is there anything else that we should know?
  • Are you pregnant?

  • Insurance

  • Please Specify

  • Primary Insurance

  • Would you like to upload / click a picture of the insurance card or enter the details of the card?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Secondary Insurance

  • Would you like to upload / click a picture of the insurance card or enter the details of the card?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Patient Consent For Electronic Insurance Claim Submission

    Please review the following if you would like our office to process your dental insurance claims electronically.

  • I AUTHORIZE the release, to my dental benefits plan administer and the CDA, information contained in claims submitted electronically. I also AUTHORIZE the communication of information related to the coverage of services described to Expressions Dental Hygiene Clinic. This AUTHORIZATION shall continue in effect until the undersigned revokes the same.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • New Patient

  • Telephone

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Insurance Policy Information

    Please provide us with your Insurance Benefits Card
  • Do you have insurance?*
  • Please specify*
  • Would you like to upload / click a picture of the insurance card or enter the details of the card?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Would you like to upload / click a picture of the insurance card or enter the details of the card?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Patient Consent For Electronic Insurance Claim Submission

    Please review the following if you would like our office to process your dental insurance claims electronically.

  • I AUTHORIZE the release, to my dental benefits plan administer and the CDA, information contained in claims submitted electronically. I also AUTHORIZE the communication of information related to the coverage of services described to Expressions Dental Hygiene Clinic. This AUTHORIZATION shall continue in effect until the undersigned revokes the same.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Medical Health History

  • Are there any diseases or medical problems that run in your family? (diabetes, cancer or heart disease)*
  • Are you being treated for any medical conditions at the present time or have you been treated within the last year?*
  • Have there been any changes in your general health in the past year?*
  • Are you taking any medications, non-prescription drugs or herbal supplements of any kind?*
  • Do you have any Allergies? (Medications, Latex, Food, Other)*
  • Please list using the categories below:*
    Rows
  • Have you ever had an uncommon or adverse reaction to any medicines to injections?*
  • Do you have/had or ever experienced any of the following Medical Conditions? Please check mark the responses and explain in short.*
    Rows
  • Do you have or have you ever had any of the following? Please check*
  • Are there any conditions or diseases not listed above that you have or have had?*
  • Do you smoke, vape or chew tobacco products?*
  • Are you nervous during dental treatment?*
  • Are you pregnant?*
  • Are you presently nursing?*
  • Do you have a family physician?*
  • Format: (000) 000-0000.

  • Dental History

  • Do you have a previous general Dentist?*

  • Information Release

  • To

     {generalDentists}

    {dentalPractice}

    {dentalPractice594}

    I authorize the above Dentist to furnish my dental records, including x-rays and the last record of the requested treatment to:

    Expressions Dental Hygiene Office
    1313 Lorne St. Unit 1
    Sudbury, ON
    P3C 5M9
    Phone#: 705.586.8686

     

    Please send digital x-rays to smileexpressionsdh@gmail.com
    I release you from all legal responsibility or liability that may arise from this authorization.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please answer the following questions.*
    Rows
  • Have you ever had any implant surgery?*
  • When was it done?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you being followed-up by a dental specialist?

  • Family Member

    • Family Member 1 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Medical History

    • Information Release

    • To {previousGeneral}

      I authorize the above Dentist to furnish my child's ({name272}) dental records, including x-rays and the last record of the requested treatment to:

      Expressions Dental Hygiene Office
      1313 Lorne St. Unit 1
      Sudbury, ON
      P3C 5M9
      Phone#: 705.586.8686

       

      Please send digital x-rays to smileexpressionsdh@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    • Please answer the following questions.
      Rows
    • Is your child being followed-up by a dental specialist?
    • Family Member 2 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral360}

      I authorize the above Dentist to furnish my child's ({name276}) dental records, including x-rays and the last record of the requested treatment to:

      Expressions Dental Hygiene Office
      1313 Lorne St. Unit 1
      Sudbury, ON
      P3C 5M9
      Phone#: 705.586.8686

       

      Please send digital x-rays to smileexpressionsdh@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    • Please answer the following questions.
      Rows
    • Is your child being followed-up by a dental specialist?
    • Family Member 3 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral361}

      I authorize the above Dentist to furnish my child's ( {name316}) dental records, including x-rays and the last record of the requested treatment to:

      Expressions Dental Hygiene Office
      1313 Lorne St. Unit 1
      Sudbury, ON
      P3C 5M9
      Phone#: 705.586.8686

       

      Please send digital x-rays to smileexpressionsdh@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    • Please answer the following questions.
      Rows
    • Is your child being followed-up by a dental specialist?
    • Family Member 4 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral362}

      I authorize the above Dentist to furnish my child's ( {name317} ) dental records, including x-rays and the last record of the requested treatment to:

      Expressions Dental Hygiene Office
      1313 Lorne St. Unit 1
      Sudbury, ON
      P3C 5M9
      Phone#: 705.586.8686

       

      Please send digital x-rays to smileexpressionsdh@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    • Please answer the following questions.
      Rows
    • Is your child being followed-up by a dental specialist?
    • Family Member 5 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral363}

      I authorize the above Dentist to furnish my child's ( {name318} ) dental records, including x-rays and the last record of the requested treatment to:

      Expressions Dental Hygiene Office
      1313 Lorne St. Unit 1
      Sudbury, ON
      P3C 5M9
      Phone#: 705.586.8686

       

      Please send digital x-rays to smileexpressionsdh@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    • Please answer the following questions.
      Rows
    • Is your child being followed-up by a dental specialist?
    • Family Member 6 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral364}

      I authorize the above Dentist to furnish my child's ( {name319} )  dental records, including x-rays and the last record of the requested treatment to:

      Expressions Dental Hygiene Office
      1313 Lorne St. Unit 1
      Sudbury, ON
      P3C 5M9
      Phone#: 705.586.8686

       

      Please send digital x-rays to smileexpressionsdh@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    • Please answer the following questions.*
      Rows
    • Is your child being followed-up by a dental specialist?
    • Family Member 7 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral364}

      I authorize the above Dentist to furnish my child's ( {name319} )  dental records, including x-rays and the last record of the requested treatment to:

      Expressions Dental Hygiene Office
      1313 Lorne St. Unit 1
      Sudbury, ON
      P3C 5M9
      Phone#: 705.586.8686

       

      Please send digital x-rays to smileexpressionsdh@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    • Please answer the following questions.
      Rows
    • Is your child being followed-up by a dental specialist?
    • Family Member 8 
    • Gender*
    • Is your child a new patient?*
    • Does your child have any previous general dentist?*

    • Information Release

    • To {previousGeneral364}

      I authorize the above Dentist to furnish my child's ( {name319} )  dental records, including x-rays and the last record of the requested treatment to:

      Expressions Dental Hygiene Office
      1313 Lorne St. Unit 1
      Sudbury, ON
      P3C 5M9
      Phone#: 705.586.8686

       

      Please send digital x-rays to smileexpressionsdh@gmail.com
      I release you from all legal responsibility or liability that may arise from this authorization.

    • Please answer the following questions.
      Rows
    • Is your child being followed-up by a dental specialist?

  • 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.

  • Exclusions for Treatment: Please answer the following:
    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.

  • 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 comply 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.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: