OPG Referral Form "(Mandatory)" indicates required fields REFERRING DENTIST DETAILSDentist Name(Mandatory) DrMissMrMrsMs Prefix First Last GDC No.(Mandatory)Preferred contact number(Mandatory)Practice Name and Post code(Mandatory)Email(Mandatory) PATIENT DETAILSAccessibility(Mandatory) Your patient is able to climb a flight of stairs. Our CBCT machine is located on the first floor. Please kindly request your patients attend without any jewellery. Thank you Name(Mandatory) MrMrsMissMsDr Select Prefix First Last Address(Mandatory) Street Address Address Line 2 City County / State / Region ZIP / Postal Code Email(Mandatory) Telephone Number(Mandatory)Date of birth(Mandatory) Day Month Year Possibility of pregnancy(Mandatory)Please selectYesNoPAYMENT OPTIONS(Mandatory) Account to referrer Patient to pay Reproduced with kind permission from Dr. Barett Andreasen, Radiodontics.com Purpose of Examination Justification(Mandatory)This is to ensure you have the required information for your clinical needs and achieved with a dose as low as is reasonably practicable (ALARP). Complying with IMER 2000 and IRR99 regulations. Please tick one or more boxes for the OPG request:- Unable to accept intra oral sensors Marked Gag Reflex or other patient factors Anatomical limitations e.g. Shallow palatal vault, insufficient lingual sulci Trismus Investigation of Pain, Swelling or Infection Jaw Injuries and Trauma Gross or extensive subgingival caries assessment Pre-Extraction and proximity to the ID nerve or other anatomical considerations Periodontitis and associated bone loss assessment , general pattern (aid staging & severity, furcation involvement and any other contributing factors) Wisdom teeth assessment and/or other tooth impactions Assessment of suspected pathology associated with teeth or within the jawbones Sinus investigation Endodontic evaluation for apical pathology, root fractures, and abnormal tooth morphology if not achievable with LCPA’s. A CBCT may also be considered Orthodontic assessment including development of teeth, possible hypodontia or ectopic teeth Implant treatment planning Other OtherIf other please give details SegmentsIf a complete panoramic image is not required, an image of specified segments (i.e. a partial OPG) can be taken. Please see the above image for segment choices 1-10. For example the sinuses and TMJ’s i.e. segments 1-5 can be omitted if they are not a region of interest Please specify below, if applicable any segments you do not wish to be included in the OPG. Please supply additional relevant clinical info or indications in the comments box below: Delivery(Mandatory)Select delivery option Email password protected copy IRMER 2000 Regulations(Mandatory) I would like this patient's radiographic examination to be be reported by your Consultant Radiologist I will make my own reporting arrangements Referrer Confirmation By submitting this form, I confirm that I am suitably qualified and entitled under current legislation to request and justify dental cone beam CT (CBCT) examinations. I understand that all requests must comply with relevant radiation protection regulations and that I am responsible for ensuring that this examination is clinically justified.
