Patient Details

REFERRING DENTIST’S DETAILS:

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.


  • I’d like to be informed of exclusive offers and other practice information YES

  • *By clicking ‘submit’ you are consenting to us replying, and storing your details. (see our privacy policy).

  • Contact Details:

    The Dental Practice
    6 Southdown Road
    Shoreham-by-Sea
    West Sussex
    BN43 5AN

    [email protected]
    01273 452947