CBCT/Radiograph Referral form

Before you refer your patient for a radiograph or CBCT, your practice needs to complete a referral agreement.

Service-Level Agreement for the referral of patients to Enhance Dental for CBCT Scans

This agreement is between:

The Receiving Practice: Cotteswold House Dental Practice, 64 Cotteswold Road, Gloucester GL4 6RH

appointments@cotteswoldhouse.co.uk

Legal Person: Rachel Addison

The Referring Clinician:

Justification: (Please tick)
I agree to use the referral criteria as per the European Guidelines

Radiation Protection No.

Provide adequate clinical information in order for each examination to be justified.

Require OPG onlyI confirm that someone adequately trained on the safe use of Dental Cone Beam CTI will report my Cone Beam CT scans acquired at Cotteswold House Dental Care.

If you require software to read x-rays please visit: https://blueskybio.com/pages/download-software

I prefer to be contacted by
CallEmail

By ticking this box I confirm that I am the representative of referring practice who is able to sign on behalf of the person who is taking the radiographs.

Patient’s details

GP Details

Does the patient visit the Hygienist regularly
YesNo

Does your patient consent to this referral and the submission of their details?
Yes

Referral Details

X-Rays

Please attach any X-Rays