Consent Form

Dental hygienists are registered dental professionals helping patients maintain their oral health by preventing and treating periodontal disease and promoting good practice. They carry out treatment directly with patients or under a prescription from the dentist.
You are able to access dental hygiene care without the need to visit a dentist.
All of our lovely hygienists are indemnified with a dental insurance company and registered with the General Dental Council (GDC).
They cannot diagnose or give prognosis for tooth decay / broken teeth, or prescribe antibiotics / painkillers or any other drug to alleviate symptoms.
If the hygienist advises you to see a dentist, it is because she feels that it is in the interests of your health to do so, and is outside the scope of what she is allowed to do.
There are very rare circumstances when she won’t begin treatment, and will insist that a dentist assesses you. These may relate to your medical history and general health, or the condition of your mouth, which gives her concern.
Consent
I have read and understood the limitations of Direct Access with a Dental Hygienist and agree to be treated under the Direct Access arrangement.
I understand that the treating hygienist is not responsible for the overall health of my mouth and that regular visits to a dentist are still recommended.
I understand that the cost of treatment will be £65.00 and agree to pay a deposit on booking, with the balance due on the day of the appointment.

Print Name (Capital Letters):
I am/am not registered with a dentist (Please circle which applies) Practice contact details (If you are registered at a practice please give the address):

You are able to access dental hygiene care without the need to visit a dentist first. The following shows the type of treatment she can undertake:
• Provide Dental Hygiene Care to a wide range of patients.
• Obtain a detailed dental history from patients and evaluate their medical history.
• Carry out a clinical examination to assess gum disease.
• Complete periodontal examination and charting, with the use of indices to screen and monitor periodontal disease.
• Diagnose and formulate a treatment plan for gum disease.
• Interpret various film views used in General Dental Practice.
• Plan the delivery of care for patients.
• Give appropriate patient advice.
• Provide preventive oral care to patients and liaise with dentists over the treatment of caries, periodontal disease and tooth wear.
• Undertake scaling on the tooth surface and above the gum, with manual and powered instruments.
• Use appropriate anti-microbial therapy to manage plaque related diseases.
• Adjust restored surfaces in relation to periodontal treatment.
• Give patients advice on how to stop smoking.
• Give infiltration and inferior dental block analgesia (local anaesthetic) with dentist’s prescription.
• If necessary, refer patients to other healthcare professional.

Dental Hygienists DO NOT:
• Restore teeth.
• Carry out pulp treatments.
• Adjust unrestored surfaces.
• Extract teeth.