OPG Referral

Dentists please complete the form below if you wish to refer patients to dentalessence for an OPG scan.

We will reply to your request as soon as we can.

    Your Practice Details (please ensure this section is fully completed)

    * Indicates required field

    Referrers Details

    Date Referred

    Patient Details

    Reason for referral *

    Medical history/additional Dental Information

    I have explained to the patient that this is a private X-ray referral and I have informed the patient the £45.00 fee is to be paid at the time of booking the appointment * (please tick)

    dentalessence 69 Station Road, Burgess Hill, West Sussex RH15 9DY

    Dentist Referrals

    We also provide the following services on a referral basis.
    Please click on the links below for the individual referral forms.

    CBCT Referral Form
    Hygienist Referral Form
    Implant Referral Form
    Oral Surgery Referral Form