Patient details

Name* Mr Miss Mrs Ms
D.O.B
Address
Telephone number
Home
Mobile
Work
E-mail address*

Medical History

Non-Smoker Smoker Ex-smoker

Dental History

Reason for referral

BPE
Radiographs available

Previous treatment completed

Supra-gingival scale
Sub-gingival scaling with local anaesthetic Date of last course

Referring Dentist

Name* Practice* Date*