OPG Referral Form

Patient Details

Title: Name: Surname: Date of Birth: Telephone (Home): Telephone (Work): Mobile: Email: Address: Postcode:

JUSTIFICATION FOR SCAN (IRMER 2000):

Implant treatment planning (assessment of position of anatomical structures, bone quality and quantity): Orthodontic assessment and planning: Impacted teeth assessment: Endodontic assessment: TMJ: Other (Please specify):

COST: £45

To be completed by the referring practitioner:

This will act as the practitioner’s electronic signature: I hereby authorize The Dental Practice to carry out an OPG on my behalf. When scanning guides are used, these guides will be prepared in advance by the referring dentist and given to the patient to bring to the appointment.

The results of the scan will be returned via email or on disc. I am responsible for assessing the data and referring to the necessary specialties as clinically indicated.

The Dental Practice and the Operator will not be responsible for assessing the OPG for the suitability of treatment or for ultimately identifying and referring pathology; by referring the patient I am accepting this responsibility. The HPA CRCE-010 guidelines suggest that attendance of Radiology Training Courses are deemed a regulatory requirement for all users of radiographs, including those who are simply referring patients for acquisition of an OPG. I accept that it is my responsibility to obtain the necessary qualification in order to refer and evaluate the data requested by me and provided by The Dental Practice. Alternatively I will arrange for a Consultant Radiologist to rule out coincidental pathology.

Referring Practitioner: Practice Name: Address: Postcode: Telephone: Email: GDC: Additional Comments:

Click here for a printable version of this referral form