OPG & CBCT Referrals Harlow & Bush Fair

Patient details

First name*

Last name*

Email address*

Telephone number

Date of birth (dd/mm/yy)

NHS number (if known)

Address (including postcode)

Name & address of GP practice (if known)

Referrer details

First name*

Last name*

Email address*

Telephone number

Position/Job title

GDC number (if registered)

Practice name & address (including postcode)

Referral details

Type of scan to be referred for:

OPG

CBCT

Area of exposure

Justification for referral

If “other assessment or planning”, please specify below:

The patient has given valid, informed consent to be referred to Keats House Dental Surgery and gives us permission to contact them regarding their referral, using the details provided.

Yes

The patient understands that all associated costs are to be paid in full to Keats House Dental Surgery and charges may be taken in advance, in order to secure an appointment.

Yes

By submitting this referral, I authorise Keats House Dental Surgery to carry out the above requested service on my behalf. The radiographs/images will be returned to me via email.

Yes

Keats House Dental Surgery will not be responsible assessing the OPG, including the diagnosis of any pathology - this responsibility lies with myself, once the OPG has been returned to me.

Yes

By clicking ‘submit referral’ you agree to Keats House Dental Surgery collecting your personal data. To learn more about how Keats House Dental Surgery collects, uses, shares and protects your personal data, please read our privacy policy.

OPG / CBCT Referrals

Refer your patient for an OPG or CBCT scan

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