OPG Referrals

Patient Details

Practice Details

Justification For Scan

Other Information

To be completed by the referring practitioner:

This will act as the practitioner’s electronic signature: I hereby authorise Church House 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.

Church House 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 Church House Dental Practice. Alternatively I will arrange for a Consultant Radiologist to rule out coincidental pathology.

I’d like to be informed of exclusive offers and other practice information

Print/Download Form

*By clicking ‘submit form’ you are consenting to us replying, and storing your details. (see our privacy policy).