Radiology Request
INCOMPLETE / ILLEGIBLE FORMS WILL BE RETURNED in line with IRMER 2000 regulations
Version: 04-07-11
Please answer the following for ALL requests:Consultant (print name):
Ward / Clinic/
Practice details:
Hospital No
NHS No
Surname
Forenames
Date of Birth
Address
□
Male □
Female
□
NHS □
PP
Postcode
Telephone
Drop Number:
Mobile
Clinical details/Relevant history
Email
(Include reason for urgency if applicable)
Clinical question:
Examination Requested:
Referrer Status: □ Consultant
□ ST □ SpR
Signature
Date
□ F1/2 □ GP GMC Code: …………………… □ Other (specify)
Referrer
Contact number:
(print name)
bleep/ dect/ phone:
Tick all that apply: □ Walking □ Chair □ Trolley □ Bed □ Portable □ Oxygen
Pregnancy status if applicable
Ambulance required? □ Yes □ No
□ Pregnant □ Not Pregnant Gestation weeks:
LMP:
Patient alerts: MRSA, Blind, Deaf etc.
Diabetic Status (please tick) □ Not diabetic
□ Diet controlled
□ Oral hypoglycaemic
□ Insulin dependent
State any known allergies, especially to Radiographic contrast media
(including the type of reaction if known)
Please answer the following ONLY for examinations which may require the administration of IV contrast agents
Renal impairment or failure □ Yes
□ No
If only the Cr level is provided, specify if patient is
□ Black
If yes, specify the eGFR ….……….. or Serum Creatinine ..……..…
□ Other
Date of result ..…………….
On Metformin
□ Yes
□ No
Asthmatic
□ Yes
□ No
On nephrotoxic drugs
□ Yes
□ No
Cardiac failure
□ Yes
□ No
Hypertension
□ Yes
□ No
Severity:
Please answer the following ONLY for MRI examinations
Cardiac pacemaker
□ Yes
□ No
Programmable hydrocephalus shunt? □ Yes □ No
Any operations involving the use of metal clips, pins, stent or implants?
□ Yes
□ No
If known, specify date and relevant details including type of clip, implant etc. ……………………..……………………………………..
Please answer the following ONLY for procedures requiring a Bowel Cleansing Solution*
1. Patient has been assessed for suitability of Citrafleet / Picolax
2. Procedure and use of Bowel Cleansing Solution has been explained to patient
Signed………………………………..….….
Date…………..……….….
*A Bowel Cleansing Solution will
not be issued to the patient unless
this section is completed and
signed.
For Departmental Use Only
Justifier / authoriser
Vetting stamp/protocol here
Attach patient
attendance label
here
Signature
Date
Date last CT scan checked
□ tick
I confirm that there is no possibility that I am pregnant.
Patient to sign:
Date:
NOTES FOR PATIENTS REFERRED BY GPs
Plain X-rays (Spine, hands, feet, etc)
These are done by appointment only. To make an appointment, please telephone the X-ray number for your
chosen site.
Specialist Examinations (Ultrasound, CT, MRI, Barium examinations, etc.)
Requests for these procedures have to be checked by Radiology staff before an appointment can be made so
that the correct procedure is booked and any preparation can be arranged.
If your examination is for one of these, you may either
1.
Post the request form, or
2.
Bring it in to the X-Ray Department.
King George Hospital or Loxford Polyclinic Tel: 9.00 am - 4.30 pm, Mon - Fri
Post forms to X-Ray Department, King George Hospital, Barley Lane, Goodmayes, Essex, IG3 8YB
X-ray
020 8970 8307
Fax
0208970 8469
(Chest X-rays can be done without an appointment between 9.00 am - 12.00 noon & 2.00 pm - 4.00 pm, Mon - Fri only in
the X-ray Dept at King George Hospital)
MRI
020 8970 5731
Ultrasound
020 8970 5754 9.00 am – 4.00 pm
Breast
020 8970 8291
All Other exams
020 8970 8119
Queen’s Hospital Tel: 9.00 am - 4.30 pm, Mon - Fri
Post forms to X-Ray Department, Queen’s Hospital, Rom Valley Way, Romford, Essex, RM7 0AG
X-ray
01708 435369
Barium studies
01708 435301
MRI
020 8970 5731
Interventional exams 01708 503106 8.30 am - 1.00 pm
CT
01708 503107
Ultrasound
01708 435451
Fanshawe Health Centre (Dagenham) X-ray & Ultrasound services only.
Post ultrasound forms to X-Ray Department, Queen’s Hospital, Rom Valley Way, Romford, Essex, RM7 0AG
X-ray - to make or change an appt 01708 435369 9.00 am - 4.30 pm, Mon - Fri
All other queries
020 8592 6274 9.00 am - 12.30 pm & 2.00 pm - 4.00 pm, Mon - Fri
(Chest X-rays can be done without an appointment between 9.00 am-12.30 pm & 2.00 pm-3.45 pm, Mon - Fri)
Ultrasound
01708 435451
Tel: 9.00 am - 4.30 pm, Mon - Fri
Please make sure that your name, address, date of birth and telephone details (including mobile) are clearly
printed in the box below and note any dates you are not available to attend. An appointment will be sent to
you in the post.
Patient name:
Date of birth:
Address:
Home telephone number:
Mobile telephone number:
I will be unable to attend on the following dates: