OPG Referrals

In accordance with guidance issued by the European Commission, we have adopted the latest best practice for dentists who refer patients for OPG referrals with us.
Online referrals are now available due to our online signature facility.

Get in touch CBCT Scan Referrals

Step 1/4: Patient Details

Patient Details

Patient Name (optional)

Patient address

Date of Birth

Patient's Email Address (optional)

Patient's Phone Number (optional)

Home

Mobile

Dentist Details

Dentist Name (optional)

Dental Practice

GDC Number

Practice Address

Phone

Justification (optional)

I agree to provide appropriate and sufficient clinical information in order for each examination to be justified, by using
……the referral criteria as set out in the European Guidelines: Radiation Protection No.136.

Date of referral:

Define the anatomical area the radiograph should cover:

Clinical context for requesting the above radiograph:

What information do you want the x-ray to provide:

Cost: (Please check to confirm)

The patient is aware of the cost of the Radiograph (£85.00) which is payable at the time of booking.

Clinical Evaluation: (Please check to confirm)

I, the referrer, will complete the clinical evaluation on the OPG Radiograph taken at South Devon Dental.

I have read and accept the website terms and privacy policy.

Yes

Signature of referring clinician:

Date:

51 Palace Avenue

01803 556422

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OPG Referrals

Patient Details

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