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


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


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.

This form is being sent securely via the Valident vForms service ensuring safe transmission of your data.


Seeing your Westbourne Grove Dental practitioner on a regular basis means that all your dental questions will be answered and any problem areas will be thoroughly examined. We pride ourselves in getting to know our patients and their dental needs, and by seeing us regularly we can build a good general picture of your oral health.


We are able to create a subtle yet effective change to your appearance, rejuvenating your skin and eradicating wrinkles. Our Treatments can be used to address many issues, such as to tackle lines on the forehead, frown lines, crow’s feet at the corner of the eyes and lines above the lips.