1. Referring Dentist Details
1.1 Practice name
1.2 Practice telephone
1.3 Practice email address
1.4 Practice address
1.5. Referring Dentist name
1.6. Date of referral
2. Patient Details
2.1. Title
2.2. Full name
2.3. Gender
Please select at least one option
Female
Male
2.4 Address
2.5. Date of birth
2.6. Mobile telephone
2.7. Home telephone
2.8. Email address
3. Scan Prescription Details
3.1 Reason(s) for referral
Please select at least one option
OPT Scan
3.2 I can confirm that no other OPT has been taken in the last 2 years
Please select at least one option
Yes
No
3.3 OPT prescription details
Please select at least one option
Standard
Front
Left
Right
3.4. Justification for exposure
This confidential form provides us with the information we require to receive a patient referral. The information contained within this form should be true and accurate to the best of your knowledge and with the patient's knowledge and consent.By submitting this form, we will securely collect your details and the patient's details. We will then store and process this information in accordance with our Privacy policy, a copy of which can be found on our website.
Please select at least one option
I understand and I agree
I have made my patient aware of this referral and the provision of their data for this purpose
Please select at least one option
I understand and I agree
I confirm that this referral complies with IR(ME)R regulations and that the imaging requested is justified for the patient's diagnosis or treatment planning.
Please select at least one option
I understand and I agree
Submit