Contact form

Hygienist Referral Form

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


Patient Details


Treatment Required



Referring Dentist Details

This will act as the practitioner’s electronic signature: I hereby authorize The Dental Practice 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.