Hygienist Referral Form

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

Practice Name: Practice Address: Practice Email: Telephone:

Patient Details

Title: Name: Address: Date of Birth: Postcode: Telephone (Day): Telephone (Eve): Mobile: Email:

Treatment Required

Full Mouth Scale and Polish: Oral Hygiene Instruction: Deep Scale Specific Quadrant(s): Full Mouth Pocket Charting: Appointment Frequency Required*: Relevant Clinical Information: Medical History:

RADIOGRAPHS INCLUDED

Attach Radiograph: Bite Wings Peri-Apical OPT

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.

Referring Practitioner: GDC Reg No: