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.
* indicates required field
(Please tick relevant boxes)
Full Mouth Scale and PolishOral Hygiene Instruction
Full Mouth Pocket Charting
Radiographs Included
YesNo
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
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.
We also provide the following services on a referral basis. Please click on the links below for the individual referral forms.
