Standard Terms and Conditions

• By sending this referral you certify that the patient consents under the referral process to have the treatment/imaging/assessment caried out at HDP and understands what it involves. I have provided the patient with adequate information relating to the benefits and risks associated with the referral. For children under the age of 16 the parent or guardian agrees.

• You undersigned agree (1) to use the referral criteria above; (2) that Referrer is GDC Registered and has the relevant training to make the referral and can be made available upon request for the person(s) named in the referral form; (3) that sufficient details are provided for each referral to allow for justification.

For Imaging requests only…

• Hazelwood Dental Practice LTD (HDP), does not warrant the accuracy, completeness, or correctness of the Images. HPD endeavours to provide the very highest quality results, however, does not accept will not accept any liability for incorrect or incomplete information on the referral form, or inappropriate or inadequate patient preparation, which may compromise the value of the final results.

• HDP endeavours to despatch the final images to the referring Dentist as fast as possible, however, equipment malfunction or pressure of other work may introduce delays. We suggest that you do not schedule an appointment to discuss the results with your patient until you have received the results from us.

• HDP 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 CBCT scan and OPG’s. HDP provides Dentists/Practices with Referral Forms which can be used for this purpose;

• Referral Criteria: The documents specified below will be used by both parties as the basis for the referral of patients and the justification of X-ray examinations: HPA-CRCE-010 Guidance on the Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment FGDP (UK) Selection Criteria for Dental Radiography, 3rd Ed. British Orthodontic Society Orthodontic Radiographs Guidelines, 3rd Ed.

• The Radiographer at HDP will take a scan with the lowest dose, smallest field of view and best resolution, according to the area of interest and clinical indications, in line with IR(ME)R and ALARP. The age, anatomy and physical build of the patient are all dependent factors and you are solely responsible for the reporting of any images requested.