AQP DIRECT ACCESS RADIOLOGY REQUEST FORM
MRI
MRI exclusions: patients with known metallic fragments in their eyes or specified implanted medical devices (e.g. cardiac pacemaker, cerebral
aneurysm clips, cochlear implant etc); pregnant women)
Please complete ALL fields below, incomplete forms may delay assessment.
All routine AQP MRI referrals are to be generated via Choose and Book.
All other MRI requests should be referred to your local Trust
Any patient with suspected cancer should be referred through the 2WW referral pathway
Please do not scan reassurances.
***Use this form for routine requests only***
*Referrer Details: (reports should be sent to the referrer)
Referrer Name:
Registered GP:
Organisation (GP practice or ESP):
Practice Code:
Tel No:
Fax No:
NHS Email Address (generic practice):
Date Referred:
Professional registration code (GMC code):
*Patient Details:
UBRN:
NHS Number:
Surname:
Date of Birth:
Forenames:
Title:
Age:
Address (full):
Postcode:
Mobile No:
Home Tel No:
Ethnic Origin
Work Tel No:
*Please state area of body to be scanned
*Relevant Clinical Indications (key symptoms and signs. If possible please include details of any previous images or scans)
*Does patient meet criteria for AQP MRI Referral? (exclusions are listed on page 2 for reference and information regarding pathways)
YES / NO
Has patient been seen by community physiotherapist prior to MRI request (for MSK referrals)
*Special Requirements (including mobility, claustrophobia, language support):
If an interpreter is required what language?
*Mandatory field
YES / NO
Exclusions for AQP Direct Access MRI

Contrast MRI
AQP Clinical exclusions

Cancer - any Patient with suspected cancer should be referred through the two week wait referral pathway;

Patients with a Body Mass Index exceeding the manufacturer’s health and safety guidance for weight limits of the MRI
unit or couch. This will be determined by the provider chosen by the patient. Any patient affected would automatically be
referred on to their local acute Trust by DRSS.

Patients with specified implanted medical devices are MRI contraindicated (e.g. cardiac pacemaker, cerebral aneurysm
clips, cochlear implant etc); and in certain cases implants are MRI conditionally safe. The referrer has a responsibility to
provide information on all such devices, but the final responsibility for safety rests with the Provider in line with Provider
protocols and relevant safety guidelines and resources.
Other AQP exclusions

Children under the age of 18

Patients requiring a general anaesthetic

Scans requiring the use of contrast

Hospital inpatients and

Non-NHS Patients.
Contraindications

a cardiac (heart) pacemaker

clips in the head from brain operations, ie aneurysm clips

a cochlear (ear) implant

a metallic foreign body in the patient’s eye

a programmable shunt for hydrocephalus (fluid on the brain)

If the patient is pregnant
Cautionary

Cerebral aneurysm clip in the brain

Heart valve Replacement

Intra-vascular stents, filters and coils

Ocular implants

Shrapnel injuries

Penile implants

Any other unknown implant until it has been determined as MRI safe

Patients with severe claustrophobia

Patients who have problems lying still or flat (such as patients with Parkinson’s, some learning disabilities, colds
(coughing or sneezing))
In some cases the patient may require an X-ray before an MRI scan, to make sure they are safe to enter the scanner.
*Mandatory field