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westbournegrove dental
  • Westbourne Grove Dental,
    18 Chepstow Corner,
    Pembridge Villas,
    W2 4XE

Online Secure Radiology Form

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  • Online Secure Radiology Form

Secure OPG/CBCT Referral Form

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Patient Details

Referring Dentist's Details

Referral Details

OPG Imaging Only

Area of Interest CBCT Only

Scan Details

Agreement

Service-Level Agreement for the referral of patients to CENTRE OF DENTAL EXCELLENCE for Dental Cone Beam CT Examinations
This agreement is between the Referring Practice, Referring Practitioner and the Centre Of Dental Excellence

Justification:

I agree to use the referral criteria as per the European Guidelines: Radiation Protection No. 172 and provide adequate clinical information in order for each examination to be justified.
I will make my own arrangement for the reporting of the CBCT scans acquired at the Centre of Dental Excellence. This will be done by someone adequately trained as per HPA-CRCE-010-Guidance on the safe use of Dental Cone Beam CT. I confirm that I am adequately trained to interpret cone beam CT scans as per HPA-CRCE-010-Guidance on the safe use of Dental Cone Beam CT. I will ensure that my training remains up to date.


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