Service Level Agreement Form

To ensure full compliance with IRMER regulations, we kindly ask that you complete the form below if this is your first time referring to us.

If you have any questions or need assistance, please don’t hesitate to get in touch:


01883 742 549
enquiries@thewhitehouse.dental


Service Level Agreement Form

Name of legal person responsible *

Practice Address *

Practice Contact Details

Receiving PRACTICE


Name of legal person responsible: Dr Sanjay Sachania 

Address: White House Dental 

1 Ivy Mill Lane

Godstone

RH9 8NH


01883 742 549

enquiries@thewhitehouse.dental


Enter below details of all persons at referring practice who will refer patients for dental CBCT examinations and/or report on dental CBCT images. 


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Signatures of agreement:


We the undersigned agree: 

For the referring practice:

For the receiving practice 


Name of Legal Person Responsible: Dr Sanjay Sachania


Signature:


Date: