OPG Referral

The following form is for another dental practice to request a private Orthopantomogram X-ray (OPG) appointment to be made at Wedgwood House Dental Practice (WHDP).
It is not to be used by a member of the public directly requesting an OPG for themselves. It is not to be used for changing an existing appointment. Should you wish to discuss appointments, please call the dental reception team on 01449 771 700.
Failure to attend a booked OPG referral appointment will result in result in a fine to the same value of the OPG fee.
See WHDP's booking policies.
Thank you.

Wedgwood House Dental Practice
100 Bury Street
Stowmarket
IP14 1HF

Phone: 01449 771 700

OPG Referral Form

Name of referring dental practice:*

This field is mandatory

Name of Dental Professional requesting referral & GDC number:*

This field is mandatory

E-mail address:*

This field is mandatory

Patient Name:*

This field is mandatory

Patient DOB:*

This field is mandatory

Patient Address:*

This field is mandatory

Patient contact number:*

This field is mandatory

Patient email address:

Where applicable, details of person with legal responsibility of patient during the OPG appointment (please include name, relationship to the patient and their contact details).

I have explained to the patient that this is a private OPG Xray referral and have informed the patient the £45.00 fee is to be paid on arrival to the appointment at Wedgwood House Dental Practice.*

This field is mandatory

I can confirm the patient is medically able to have a radiograph taken and I have asked them to remove all jewelry and piercings in the head and face.*

This field is mandatory

I hereby authorise Wedgwood House to carry out an OPG on my behalf. The results of the radiograph will be returned to the Patient's email address (or if not given, the referring practice's email).*

This field is mandatory

I have obtained consent from the patient to share their personal data in line with the UK Data Protection Act (GDPR). Patient is aware their data from this form will be stored electronically by WHDP.*

This field is mandatory

The patient may revoke their consent at any time. And they understand that the deletion of dental records is prevented by the UK DPA 2018.*

This field is mandatory

Please describe the reason for requesting the OPG at Wedgwood House Dental Practice:*

This field is mandatory

Additional Comments:

I am over 18 years of age and a UK citizen. I hereby agree that my & the patient I am medically in charge of, personal data entered in this OPG Web Ref Form will be stored electronically by Wedgwood House Dental Practice and will be processed for the purpose of taking an Orthopantomogram x-ray (OPG x-ray) and sharing the results as needed. I am responsible for assessing the data and referring to the necessary specialities as clinically indicated. Wedgwood House and the operator will be not responsible for assessing the OPG for the suitability of future treatment or for immediately identifying and referring pathology. I certify that I have obtained the necessary qualifications in order to refer and evaluate the data requested by me and provided.*

This field is mandatory

* Indicates required fields

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Thank You! We will try to respond as timely as possible.

OPG Referral

OPG Referral Form

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