Hygienist referral (Wicklow Drive) Referring dentist * Referral completed by (for commission) * Patient details * First Name Last Name Pt contact number * Pt address * Pt DOB * Practice patient is registered at * New Parks Wicklow Netherhall Saffron MH and/or other comments Dentist routine recall * 3 monthly 6 monthly 9 monthly 12 monthly Bone loss * Stage 1 Stage 2 Stage 3 Stage 4 Unknown Topical numbing * Yes No If local is to be used. * Lidocaine 2% Articiane 4% Scandonest Infiltrations / IDB * Infiltrations IDB Not a hyg referral Choose hygienist treatment * BPE Full periodontal assessment Oral hygien instructions Professional mechanical plaque removal Subgingival instrumentation Review pt and provide further treatment Thank you!
