Referral Form for OPG at Brighton Dental Clinic

Patient Details (All fields with an * are required)

Mr Mrs Miss Ms Other

Name *

Address

Postcode *

Is this referral urgent? * Yes No

Date of Birth *

Telephone (Day)

Telephone (Evening)

Mobile *

Email *

Referring Dentist Details (All fields with an * are required)

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.

Referring Practitioner *

Date of Referral

Practice Website *

There is no website

OPG Referral

OPG Referral Form

Brighton Dental Clinic

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OPG Referral

OPG Referral Form

Brighton Dental Clinic

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