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.