Hygienist Referral Form

  • * These fields are compulsory
  • New patient referral :- level 1 or 2 [please indicate which] and level 3

  • Discussion about any symptoms and causes for concern
    Review of medical history
    Soft tissue check
    B.P.E. [Basic Periodontal Examination]
    Oral health guidance
    Scale and polish, if appropriate
    Arrange further appointments with the patient as necessary
  • Discussion about any symptoms and causes for concern
    Review of medical history
    Soft tissue check
    Full periodontal Charting of pockets (inc. Bleeding, Mobility etc)
    Oral health guidance and initial sundry items
    Arrange further appointments with the patient as necessary
  • Used Dosage Frequency
    L.A to use
    Flouride Vanish
    Flouride Toothpaste 1.1%
    or 1.62%
  • 1 year
    2 years
    3 years
  • 6 weeks
    3 months
    6 months
    1 year
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