Referring Dentist Details Referring Practice Details Patient Details TitleMrMrsMissMsDr Radiograph Referral: Radiograph CBCTOPGBitewing (For Gag Patients) For Treatment Assessment * ImplantOrthodonticEndoTMJOther Treatment Referral: Treatments ExtractionEndodonticsRestorativeImplantOral SurgeryOral MedicineOrthodonticsInvisalignCosmotic DentistryFacial Treatment Optional Under Sedation I have obtained consent from the patient to share their personal data via non- encrypted email, in line with GDPR data security. I hereby authorise Olive Tree Dental to carry out a CBCT/OPG on my behalf. The results of the radiograph will be returned via email. I am responsible for assessing the data and referring to the necessary specialties as clinically indicated. Olive Tree Dental and the operator will not be responsible for assessing the CBCT/OPG for the suitability of treatment or identifying any pathology (including incidental findings). By referring this patient, I am accepting this responsibility. I certify that I have obtained the necessary qualifications to refer and evaluate the data requested by me and provided by Olive Tree Dental.