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Brighton Dental Clinic

OPG Referral

Patient Details

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All fields with an * are required

Justification for OPG

Correspondence Details

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This will act as the practitioner's electronic signature: I hereby authorize Brighton Dental Clinic to carry out an OPG on my behalf.

I am responsible for assessing the data and referring to the necessary specialties as clinically indicated.

Brighton Dental Clinic and the Operator will not be responsible for assessing the OPG for the suitability of treatment or for ultimately identifying and referring any pathology; by referring the patient I am accepting this responsibility. If I identify any abnormality that I cannot fully diagnose it is my responsibility to arrange for a Consultant Radiologist to rule out coincidental pathology.