Service Level Agreement Form

Fill in the service level agreement form below

Referring Practice Details

Address of Referring practice:

Telephone:

Email:

Name of legal person:

Name(s):

GDC/GMC Reg No:

Referrer:

Operator (reporting):

Signatures of agreement:

I agree (1) to use the referral criteria stated above; (2) that evidence of adequate training has been provided for each of the persons named above appropriate to their IRMER roles; (3) that adequate information will accompany each referred patient to allow the justification process to proceed, as set out in the attached Standard Referral Form.

Agree to terms:

Case Study: Buried Root

Mr GD from Swansea (West Wales). Mr D was a self-referral and not aware of the buried canine in his upper left jaw...
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Case Study: Lingual Shelf

Mr AA from Newport (South Wales). From the 2-D image (DPT view) it appears that there is plenty of bone height above the...
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Case Study: Endodontic

Mrs AE from Usk (Monmouthshire). A two dimensional image of this tooth would not show the true extent of the roof-fracture...
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Case Study: Maxillary Sinus

Mr NM from Crickhowelll (Powys). The 2D OPT image for Mr M helped us realise the extent of the maxillary sinuses and the resulting lack of bone height...
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Website was last updated at 02/08/2017 | General Dental Council