Hygienist Referral form

Patient Details

Referring Dentist Details

Further Information

Treatment Required

Radiographs Included

Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF.

Referring Dentist's Statement

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 FULL RESPONSIBILITY FOR THE PATIENT’S PERIODONTAL CARE AND RESOLVE THE TREATING HYGIENIST/S FROM ANY LIABILITY.

I accept that the hygienist cannot and would not be expected to make a diagnosis beyond their scope of practice.