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 £65.00 fee is to be paid at the time of booking the appointment * (please tick)

    I hereby authorise dentalessence to carry out an OPG on my behalf. The results of the radiograph will be returned via email. I am responsible for assessing the data and referring to the necessary specialties as clinically indicated. dentalessence and the operator will not be responsible for assessing the OPG for the suitability of treatment of for immediately identifying and referring pathology; by referring this patient I am accepting this responsibility. I certify that I have obtained the necessary qualifications in order to refer and evaluate the data requested by me and provided by dentalessence. I have obtained consent from the patient to share their personal data via non-encrypted email, in line with GDPR data security.

    Dentist Referrals

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

    69 Station Road • Burgess Hill • West Sussex RH 15 9DY • 01444 232 292 • burgesshill@dentalessence.co.uk
    19a Broadwater Street West • Worthing • West Sussex BNl 4 9BT • 01903 823 838 • worthing@dentalessence.co.uk
    39 St Mary’s Road • Weybridge • Surrey KTl 3 9PT • 01932 857 998 • weybridge@dentalessence.co.uk
    43 Busticle Lane • Sompting • West Sussex BN 15 0DJ • 01903 754 224 • sompting@dentalessence.co.uk
    49 Hazelgrove Road • Haywards Heath • West Sussex RH 16 3PH • 01444 452 112 • haywardsheath@dentalessence.co.uk