OPG Referral

OPG Referral Form

* Indicates required field

Referrer's Name *

First

Last

Practice Address *

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Line 2

City

State

Zip Code

Country

Patient Name *

First

Last

Patient Address *

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Line 2

City

State

Zip Code

Country

Referrer's Email *

Patient Email *

Referrer's Phone Number *

Patient Phone Number *

Justification for OPG *

Patient DOB *

How would you like to receive the image *

Disc drive Secure email Printed

Declaration

This will act as the practitioner’s electronic signature: I hereby authorise Birchfield Dental Practice to carry out an OPG on my behalf. The results of the scan will be returned via secure email, on disc or in printed form. I am responsible for assessing the data and referring to the necessary specialties as clinically indicated. Birchfield Dental Practice and the Operator will not be responsible for assessing the radiograph 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 are deemed a regulatory requirement for all users of radiographs, including those who are simply referring patients for acquisition of a radiograph. 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 Birchfield Dental Practice. Alternatively I will arrange for a Consultant Radiologist to rule out coincidental pathology.

Referrer's Name *

First

Last

Referrer's GDC No. *

Submit