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
