Hygienist Referral

Dentists please complete the form below if you wish to refer patients to a dentalessence Hygienist.

We will reply to your request as soon as we can.

Your Practice Details (please ensure this section is fully completed)

* indicates required field

Patient Details

Treatment Required

(Please tick relevant boxes)

Full Mouth Scale and PolishOral Hygiene Instruction

Full Mouth Pocket Charting

Radiographs Included


Attach Radiograph (file types accepted gif/png/jpeg)

File name to include referring dentist name, patient initials and patient DOB.

OPGBite wingsPeri-Apical

Will the patient benefit from sedation


Referring Dentist Details

This will act as the practitioner’s electronic signature: I hereby authorize dentalessence to carry out hygiene treatment on my behalf. I have explained the need for referral to a hygienist and obtained my patient’s consent for the treatment to be carried out.

I accept that the hygienist cannot and would not be expected to make a diagnosis beyond their scope of practice.

Dentist Referrals

We also provide the following services on a referral basis.
Please click on the links below for the individual referral forms.

CBCT Referral Form
Implant Referral Form
OPG Referral Form
Oral Surgery Referral Form