Complete the online form below to submit an OPG referral

If you require any assistance in completing the form please call 01892 254 879

"*" indicates required fields

Patient Details

Title*

Name*

First Name Surname

DOB*

Tel (Home)*

Tel (Mobile)*

Email*

Address*

Street Address Address Line 2 City County Postcode

Justification for Radiograph

Other Justification

Cost £85

Payment*

Referrer

Patient

To be completed by referring practitioner

I hereby authorise The Dental Box to carry out an OPG on my behalf. The results of the radiograph will be returned via email. I am responsible for assessing the data and referring to the necessary specialties as clinically indicated. The Dental Box and the operator will not be responsible for assessing the OPG for the suitability of treatment of for immediately identifying and referring pathology; by referring this patient I am accepting this responsibility. I certify that I have obtained the necessary qualifications in order to refer and evaluate the data requested by me and provided by The Dental Box. I have obtained consent from the patient to share their personal data via non-encrypted email, in line with GDPR data security.

I hereby authorise The Dental Box*

Authorise

Referring Practioner*

GDC*

Practice Name*

Practice Address*

Street Address Address Line 2 City County Postcode

Telephone*

Email*

Additional Comments

CAPTCHA

OPG Referral Form

Complete the online form below to submit an OPG referral

Patient Details

Justification for Radiograph

Cost £85

To be completed by referring practitioner

145 London Road, Tunbridge Wells, Kent, TN4 0NA

01892 254 879 | info@thedentalbox.co.uk