Online Referrals

Dentist Details (IRMER Practitioner)

Dentist Address

Dentist Telephone

Dentist Email

Have you a service level agreement in place with Billingshurst Dental Practice?

SECTION A: PATIENT DETAILS

Title

Name

Date of Birth

Address

Phone (Home)

Phone (Work)

Phone (Mobile)

Treatment for ReferralCBCT ScanOPGOPG/BW

Areas you wish investigated:

Clinical reasons for referral:Relevant results of history, clinical examination, and any other imaging:What information do you want the dental CBCT or OPG to provide?

Please tick box to confirm:A recent radiograph is enclosedThe patient has been given an estimate of cost:The patient has been informed of payment policy

SECTION B: TO BE COMPLETED BY THE RECEIVING PRACTICE / X-RAY IMAGING FACILITY

Justification

IRMER Practitioner Name:IRMER Practitioner Signature:IRMER Practitioner Signed Date:Details of radiographic image(s) and/or scan(s) authorised:

Radiograph Information

Operator name:Operator signature:Date of radiographic exposure(s):Exposure factors used:

SECTION C: TO BE COMPLETED BY THE OPERATOR (REPORTING)

Clinical evaluation (reporting)

Reporting operator name:Reporting operator signature:Reporting operator signed date:Outcome:

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