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

    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

    YesNo

    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