HYGIENIST REFERRAL

Treatment required Treatment required Full mouth Scale and Polish Oral Hygiene Instruction

Full Mouth Pocket Charting Full Mouth Pocket Charting Full Mouth Pocket Charting

File name to include referring dentist name, patients initials and patient DOB File InputNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png. Max. file size: 1 MB

Will the patient benefit from sedation? Will the patient benefit from sedation? Yes No

Referring dentists details I have explained the need for referral to a hygienist and obtained my patient's consent for the treatment to be carried out.

Practitioner Authorisation and Responsibility Statement

This serves as the practitioner’s electronic signature and authorisation for Ferring Dental Clinic to provide hygiene treatment on my behalf.

The need for referral to a dental hygienist has been explained and their consent has been given. I accept full responsibility for the patient’s ongoing periodontal care and release the treating hygienist(s) from any associated liability.

I acknowledge that the hygienist’s role is limited to the scope of their professional practice and that they are neither expected nor permitted to make diagnoses beyond that scope.

Hygienist Referral Form

Practitioner Authorisation and Responsibility Statement