Patient's Details:

Title (required)

First name (required)

Last name (required)

Date of birth (required)

Address (required)

Post code(required)

Home tel:

Mobile tel:

Email (required)

Referring Dentist Details:

Dentist name (required)

Practice Name (required)

Practice Address (required)

Post code(required)

Practice Phone (required)

Practice Email (required)

Justification For OPG (required under IR(ME)R 2017 (must be completed):

OPG Requirements:

Full with TMJsFull without TMJsSectional Right SideSectional Left Side

Please inform patient of the price OPG £75.
To view are scan you will require the Romexis software viewer.
We do not report on scans, if you do require a report you can contact JM Radiology

Accompanying files