Botesdale Dental Practice & Implant Clinic

A family run family focused practice

01379 897176    reception [at] botesdaledental [dot] co [dot] uk
  01379 897176   reception [at] botesdaledental [dot] co [dot] uk
Dental implants

Referrals

We are pleased to offer a reliable and efficient CBCT and OPG referral service for our professional colleagues.

We provide high-quality imaging using the latest dental radiographic technology, ensuring accurate diagnostics and seamless collaboration.

Our dedicated team is committed to delivering clear, precise scans with fast turnaround times, enabling you to plan and treat with confidence. We accept referrals from all dental professionals and guarantee a welcoming, professional experience for every patient you entrust to us.

Whether you require 3D CBCT imaging for complex diagnostics or OPG radiographs for routine assessment, we are here to support your clinical needs with excellence and efficiency.

Dental Patient receiving treatment

Please complete both the forms

Please note: You only need to complete the Service Level Agreement form once. If you have previously submitted a referral and this included the Service Level Agreement, you do not need to complete it again.

Referral form

    Referring Dentist Details

    Patient Details

    Clinical Information


    Upper Right QuadrantUpper Left QuadrantLower Right QuadrantLower Left QuadrantMaxillaMandibleTMJOther

    Imaging Requirements


    Small Field of View (FOV)Medium Field of View (FOV)Large Field of View (FOV)


    Standard ResolutionHigh Resolution (where clinically justified)

    Reporting Requirements


    Full Radiology Report Required ( Additional fee required)Report by Referring Clinician

    Referrer Declaration

    I confirm that I am referring this patient for a CBCT scan in accordance with current radiation safety guidelines and that the exposure is justified for diagnostic purposes.

    Service level agreement

      Referring Dentist Details

      Referring Practice

      Receiving Practice

      Botesdale Dental Practice & Implant Clinic
      The Drift
      Botesdale
      Suffolk
      IP22 1DH
      01379 897176
      reception [at] botesdaledental [dot] co [dot] uk
      Dr Martin Sulo

      Referral Criteria

      The document specified here will be used by both parties as the basis for the referral of patients and the justification/authorisation of dental radiographic examinations.

      Entitlement of People

      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.

      Referrer 1


      ReferrerOperating (reporting)

      Referrer 2


      ReferrerOperating (reporting)

      Referrer 3


      ReferrerOperating (reporting)

      Agreement

      We agree: (1) To use the referral criteria above; (2) That evidence of adequate training has been provided for each of the people named above appropriate to their IRMER17 roles; (3) That adequate information will accompany each referred patient to allow the justification process to proceed.