Dentist Referral

OPG X-RAY REFERRAL FORM FOR DENTISTS

For referrals from registered dental professionals

Riverside Dental Practice provides an OPG (Orthopantomogram) imaging service for local dental practices.

We welcome referrals from dentists who require OPG imaging for diagnosis, treatment planning, or further assessment.

Please Complete the Referral Form Below:

1. Patient Details

Patient Full Name

Address

Phone Number

2. Referring Dentist/ Practice Details

Referring Dentist Name

Referring Dentist Email

GDC Number

Dental Practice Name

Practice Address

Practice Email

Practice Phone Number

3. Radiographic Request

Requested examination: OPG (Orthopantomogram)

Urgency

Routine Urgent

Clinical Justification/ Reason for OPG

Relevant Clinical Findings/ Diagnosis/ Treatment Planning Information

4. Referring Dentist Declaration

I confirm that I am the referring dental professional and that the requested OPG is clinically justified. I have assessed the patient and provided sufficient clinical information to enable appropriate consideration of the radiographic examination. I confirm that the patient has been informed about the referral and has consented to the necessary sharing of their personal and clinical information for the purpose of arranging and undertaking the examination.

5. Patient Information/ Practice Use

The patient should be informed that the OPG is being requested by their referring dentist and that the radiographic examination will be undertaken following appropriate assessment. The radiographic image/report will be made available to the referring dentist in accordance with the agreed referral process.

Patient Appointment Date (if known)

Additional Information/ Instructions

Riverside Dental Practice

OPG Referral Service

Address

Riverside Dental Practice, Flat 108 Lower Richmond Road, Putney, London SW15 1LN

Phone

02087883341

Email

info@riversidedentalpracticeputney.com