OPG Imaging Request

OPG Referral

Date of referral

Referrer Details

Referring dentist's name

GDC number

Practice name

Practice address

Address Line 1

Address Line 2

City

Post Code

Practice phone number

Practice email address

Referring dentist's mobile (optional)

Patient Details

Title

First Name

Last NName

Date of birth

Daytime phone

Mobile

Patient Email

Patient address

Address Line 1

Address Line 2

City

Post code

Relevant medical history. Please specify medications and allergies.

Additional Information

Clinical justification

In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental OPG.

Clinical justification - Other

Reporting

All reporting for the requested images is to be carried out by referring clinician as required by IR(ME)R 2000/2006

Payment

Who is responsible for payment?

Patient at appointment

Invoice referring practitioner

I confirm that the patient has given consent to be contacted by Sharrow Vale Dental Care

Via telephone

Via telephone & letter

Via telephone, letter & email

I certify that the information provided on this referral form is accurate to the best of my knowledge, and that the patient has consented to onward referral for the provision of specialist treatment/services from Sharrow Vale Dental Care

Yes

This will act as the practitioner’s electronic signature: I hereby authorise Sharrow Vale Dental Care to carry out an OPG on my behalf. The OPG will be returned via email or on disc. I am responsible for assessing the data and referring to the necessary specialties as clinically indicated. Sharrow Vale Dental Care 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 is 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 Sharrow Vale Dental Care. Alternatively, I will arrange for a Consultant Radiologist to rule out coincidental pathology.

Referring dentist's signature

Mon	8:30 - 6:00pm
Tues	8:30 - 5:00pm
Wed	8:30 - 6:00pm
Thur	8:30 - 5:00pm
Fri	8:30 - 5:00pm

Referrer Details

Patient Details

Clinical justification

Reporting

Payment

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