OPG Referral

Referrer Details

Patient Details

Clinical justification

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


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


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