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Hygienist Referral Form

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

 

Patient Details

 

Treatment Required

RADIOGRAPHS INCLUDED

 

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.


  • 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).