Self referral form for Undergraduate Care with Dental Hygienist-Therapist students only. Date of birth Surname Forename Male or female Male Female Surname (family name) at birth (if different) Contact Address Phone number Email address GP name and address Language Do you need to communicate in a language or mode other than English? If yes, please specify: Do you currently have your own Dentist? Yes No Have you attended the School of Hygiene-Therapy before? Yes No Have you ever attended Edinburgh Dental Institute? Yes No Reason for Self-Referral Is there any other information we need to know? I have read and understood the information leaflet Yes Please tick the box to indicate that you have read and understood the information leaflet 'Treatment with Undergraduate Dental Hygienist-Therapists at Edinburgh Dental Institute- Information for Patients’ which can be downloaded on the previous page. How did you hear about us? This article was published on 2024-01-29
