Imaging Request Form
X-RAY, MRI, ULTRASOUND, CT, NUCLEAR MEDICINE
MAMMOGRAPHY, DEXA
PATIENT NAME:
GP NAME:
DOB:
GP ADDRESS:
MRN:
ADDRESS:
GP TELEPHONE:
NHS ☐ PRIVATE ☐
PATIENT ARRIVAL: Walking ☐ Bed ☐ Chair ☐ Trolley ☐
PRIORITY: Urgent ☐ Routine ☐ Planned Wait ☐
NHS NUMBER:
FOR FEMALES 12-55 YEARS
WHERE X-RAYS INCLUDE
ABDOMEN/PELVIS
LMP
EXAMINATION:
Yes
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PATIENT PREGNANT OR MAY BE PREGNANT
/
No
☐
/
CLINICAL QUESTION AND RELEVANT PREVIOUS MEDICAL HISTORY:
Details (including any surgery, current medication, and known allergies)
IMAGING REQUESTED: MRI ☐ CT ☐ X-RAY ☐ NMED ☐ US ☐
SAFETY CHECKS: DOES THE PATIENT HAVE
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Cardiac Pacemaker
Cranial aneurysm clips
Replacement heart valve
Claustrophobic
Surgery in last 2 months
History of vascular surgery/stents
Metal implants/prosthesis
Orbital/other metal fragments
History of renal impairment
Asthma
(YES or NO)
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☐
☐
☐
☐
☐
☐
☐
☐
☐
e-GFR Date:
MAMMOGRAPHY ☐
DEXA ☐
Must be completed for all MRI/CT exams
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
/
/
e-GFR Value:
CLINICIAN’S DETAILS IR(ME)R 2000 Regulations require the referrer to supply sufficient medical data to justify the examination.
The referrer must sign this form to affirm this
NAME:
DATE:
TELEPHONE/EMAIL:
VETTED BY:
SIGNATURE:
For general enquiries
Tel: 01737231604
Fax: 01737231923
Address: Canada Avenue, Redhill, Surrey RH1 5RH
Author: Technical Support Officer
Updated: November 2015 | Review April 2017
DI-REQFORM-NOV2015