OPG Referral

01903 650222

We can help provide support for clinical evaluation of the patient’s dental condition with our OPG services. OPG will provide a comprehensive panoramic view of the maxillofacial region, including the maxilla, mandible, teeth, and temporomandibular joints.

OPG Referral Form

£60

Please complete the form below to refer patients.

*Indicates required field

Patient details

Address

Postcode

Date of birth

Contact number

Email

Reason for referral

Medical history

Referring dentists details

GDC Reg No.

Practice name

Practice address

Postcode

Practice Email

Practice contact number

Practitioner Authorisation and Responsibility Statement

This serves as the practitioner’s electronic signature and formal authorisation for Findon Dental Clinic to perform an OPG (Orthopantomogram) on my behalf.

The scan results will be supplied either via email or on disc. I acknowledge that I am responsible for reviewing the imaging data and referring the patient to the appropriate specialist as clinically indicated.

I understand that Findon Dental Clinic and the Operator are not responsible for assessing the OPG for treatment suitability or for identifying any pathology. By referring the patient, I accept full responsibility for these clinical assessments and any required onward referral.

I accept that it is my responsibility as a dentist to hold the necessary qualifications and follow the guidelines (IRMER 17) to refer patients and interpret the imaging data provided by Findon Dental Clinic.

Please confirm Please confirm I have explained to the patient that this is a private X-ray referral and a fee is required at time of booking (please tick).*