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