Service-Level Agreement for the referral of patients to Enhance Dental for CBCT Scans

This agreement is between:

The Receiving Practice:

Enhance Dental
1 Fidler Lane, Garforth, Leeds, LS25 1DR
01132 860 232
[email protected]
Legal Person*: Mark Hanson

The Referring Clinician:

Name:

Address:

Tel:

Email:

Referrers GDC No.:

Justification: (Please tick left hand box):I agree to use the referral criteria as per the European Guidelines: Radiation Protection No. 172 and provide adequate clinical information in order for each examination to be justified.

Reporting: (Please tick left hand box of one of the following)I will make my own arrangement for the reporting of my Cone Beam CT scans acquired at Enhance Dental. This will be done by someone adequately trained as per HPA-CRCE-010-Guidance on the safe use of Dental Cone Beam CTI will report my Cone Beam CT scans acquired at Enhance Dental. I confirm that I am adequately trained to interpret cone beam CT scans as per HPA-CRCE-010-Guidance on the safe use of Dental Cone Beam CT. I will ensure that my training remains up to date.

For the Referring Clincian

Signature:

Date:

*The person who signs here should be a suitable representative of the practice who is able to sign on behalf of the person who is taking the radiographs.