CBCT/OPG Service Level Agreement

CBCT/OPG Service Level Agreement

For the referral of patients for dental CBCT and OPG examinations. Must be completed by all referring practices ONCE.
RECEIVING PRACTICE

IKON Dental Specialists, 69 The Avenue, West Ealing, London, W13 8JR

Tel: 020 8997 2888

Email: reception@idspecialists.co.uk

Owner/ Principal Dentist: Dr Manish Bose (GDC: 72111)
Referring Practice*

Practice Name

Street Address Line 1

Address Line 2City

Postal / Zip Code
Referral criteria

The evidence and confirmations provided with this form will be used by both parties as the basis for the referral of patients and the justification/authorisation of dental radiographic examinations.
Enter below the details of all people at the referring practice who will refer patients for radiographic examinations and/or report on dental images. Evidence of suitable training must be provided. *
Enter below the details of all people at the referring practice who will refer patients for radiographic examinations and/or report on dental images. Evidence of suitable training must be provided.
Enter below the details of all people at the referring practice who will refer patients for radiographic examinations and/or report on dental images. Evidence of suitable training must be provided.
Please upload evidence of adequate training for each of the people named above*

Cancelof
Agreed by Receiving Practice

Signed by Dr Manish Bose

Signed as per date equal to form submission date
Agreed by the referring practice*

First NameLast Name
Email*
example@example.com
Signature of above on behalf of the referring practice
Should be Empty:

CBCT/OPG Service Level Agreement

Referral criteria