Stratford Dental

Trinity House,
Aintree Road,
Stratford upon Avon, Warwickshire,
CV37 9FL

Opening Hours

Monday: 8.00am – 6.30pm
Tuesday – Thursday: 8.00am – 5.00pm
Friday: 8.00am – 3.00pm
Saturday*: 8.30am – 12.30pm

* Open one Saturday per month

Call Us

01789 292398

E-Mail Us

reception@stratforddental.co.uk

Referral Form

We welcome your CBCT Scan and OPG referrals to Stratford Dental in Warwickshire. If you are referring using the online form, please fill out the Radiography Service Level Agreement and attach it to the form.

Download Service Level Agreement

Referral type *

CBCT Scan

OPG

Referring Dentist Name *

Referring Dentist Number *

Referring Dentist Email Address *

Referring Dentist Address *

Patient Title *

Date of Birth *

Patient Email Address *

Patient Number *

Patient Address *

Clinical context for requesting a dental CBCT examination *

Relevant results of history, clinical examination and other imaging *

What information would you like the dental CBCT to provide? *

Define the anatomical area that the scan(s) should cover *

Reporting of Scans *

I fully understand and accept that Stratford Dental does not report on the scans and radiographs requested by referring GDPs.

I am the IR(ME)R referrer/operator. I am adequately trained to report on my patients scan.

Dentist Declaration *

Confirm that you refer in accordance with published guidance criteria.

Confirm that you have fulfilled the standard education requirements in the use of ionising radiation and radiation protection and provide certification to show that you have undertaken additional training for CBCT Referrers.

These guidelines are available on:https://assets.publishing.service.gov.uk/media/5a7d4f13ed915d321c2de451/HPA-CRCE-010_for_website.pdf

If you would like to attach radiographs, clinical notes, and evidence of level 1 CBCT training, please use the upload facility below. The file types to upload are JPEG, PNG, PDF, and ODT. There is a 3 MB limit per upload area.

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