FHDC is accepting referrals for OPG.

It is important for us to have correct information for all our referral patients. Please take time to complete the form and answer the following questions. Providing this information helps us treat our patients safely. All information provided will be kept strictly confidential.

50% of our total cost price (£100) will be taken on booking.

Please complete this referral form & press the green send button below

Patient title(Required)

First Name(Required)

Surname(Required)

Phone(Required)

Your Email(Required)

Your address(Required)

Your postcode(Required)

Referring Dentist

Referring Dentist Name(Required)

Referring Practice Name(Required)

Referring Practice Number(Required)

Referring Practice Email(Required)

Communication

Please tick your preferred contact method(s) by the practice. This includes appointment reminders and general communication:

Communication(Required)

Phone via mobile

Phone via home

Reason for Radiograph

Reason for Radiograph(Required)

If X-rays are available, please upload here...

Max. file size: 50 MB.

Please check the information is correct and click the send button below. By sending this information you are confirming that you agree to the disclaimer* below.

Thank you. Once you have clicked send, please wait a moment for any files to upload. If you do not receive an automatic email acknowledgement within a few minutes, there may have been an issue with your upload. Please try again or contact our reception team.

*I hereby authorise Far Headingley Dental Care (FHDC)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. FHDC and the operator will not be responsible for assessing the OPG for the suitability of treatment or 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 FHDC. I have obtained consent from the patient to share their personal data via non-encrypted email, in line with GDPR data security.

We are committed to protecting your personal information. Please see our privacy policy (opens in a new window) to find out how your information is stored and protected.

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OPG Referral Form