Dental Radiography Referral Form

Patient Full Name

Patient D.O.B

Patient Email Address

Patient Contact tel

Referrer Name

Referrer GDC No

Referrer Email address

Date of referral

Name of Operator (Reporting) [if different from above]

Type of Radiograph *Please fill the required field.

Is the patient coming with a radiographic template?

Area of interest for conducting radiographic examination (e.g full maxillary arch, LL6 etc.)

Justification for requesting the above examination:

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Service Level Agreement

Both the referrer and Smile Zone will use “Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment 2nd Edition by PHE and FGDP 2020” as the basis for the referral of patients and the justification/authorisation of dental radiographic examinations
Adequate evidenced training exists for the referrer named above appropriate to their IRMER17 roles of referrer and operator (reporting)
The patient consents under the referral process to have an x-ray exposure and understands what it involves. I have provided the patient with adequate information relating to the benefits and risks associated with the radiation dose. For children under the age of 16 the parent or guardian agrees.
This patient is not subject to safeguarding.

I have read and agree to abide by Smilezone Dental's Standard Terms and Conditions and Privacy Policy

Standard Terms and Conditions

Disclaimer: Printed Reports, SimPlant conversions,3D reconstruction services, custom 3D reconstruction services, panoramic reconstructions, nerve segmentation, data networking and any other services provided by Smile Zone delivered "as is" without warranty, express or implied, statutory or otherwise, as to any matter whatsoever, including without limitation, merchantability and fitness for a particular purpose. Smile Zone makes no warranty as to the sufficiency or suitability of said services and does not warrant the accuracy, completeness or correctness of the services. The results must be verified by a medical doctor to ensure accuracy before being used and compared to the medical images provided to the company. In no event will Smile Zone be liable to anyone for action taken in connection with the use of said services.
Smile Zone endeavours to provide the very highest quality results, however, Smile Zone will not accept any liability for incorrect or incomplete information on the Booking Form, or inappropriate or inadequate patient preparation, which may compromise the value of the final results.
Smile Zone endeavours to dispatch the final images to the referring Dentist/Surgeon as fast as possible, however, equipment malfunction or pressure of other work may introduce delays. Smile Zone reserves the right not to accept referrals in such cases.
Smile Zone will not accept any liability for consequential losses arising from delays whether because of late or non-payment, non-receipt of a Booking Form, pressure of other work, or for any other reason
Smile Zone suggests that you do not schedule an appointment to discuss the results with your patient until you have received the results from us.
Smile Zone cannot guarantee that computer-readable images be compatible with your computer system
Please note that under IR(ME)R 2000 and SI 478 of 2002 a clinical justification must be provided for each dental CT scan. Smile Zone provides Dentists/Surgeons with Referral Forms which can be used for this purpose;
Smile Zone accepts referrals from GMC/GDC Registered Practitioners only.

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