IMAGING REQUEST FORM for Lower GI Studies
St Helens and Knowsley Teaching Hospitals NHS Trust, Warrington Road,
Prescot, Merseyside
Patient's details (or affix ID label)
Patient category
NHS
PP
Cat II GP
Other
Name........................................................................
Address.....................................................................
..................................................................................
Postcode............................ Tel.................................
DOB..............................Hosp.No..............................
NHS No.....................................................................
Ward/Dept....................................Date....................
Consultant/GP..............................................
Signature..................................................................
Print name...............................................................
Designation..................................Bleep No...............
INCOMPLETE OR ILLEGIBLE FORMS WILL BE RETURNED
Examination Requested
IMPORTANT
Is the patient able to safely tolerate bowel prep? Have you
completed a risk assessment following NPSA/2009/RRR012?
Examinations will only be accepted without prep with prior
consultation with Radiology.
Yes
Relevant clinical history:
N/A – please state reason
No
Pregnancy rule
Any possibility of pregnancy? Yes/no
LMP................Signed...............................
What is the clinical question?
Known infection risk
Eg. MRSA, HepB or HIV
Previous imaging?
Priority (Please tick)
Routine
Semi-urgent
All 3 sections must be completed.
Walking / Chair / Trolley / Bed / Mobile
TRANSPORT DETAILS
Ambulance
Contraindications to IV Contrast
eGFR
DIABETIC (ON METFORMIN)
ASTHMA
ALLERGIES
RECENT MI
MYELOMA
GP Stamp
Urgent
yes / no
Escort yes / no
For radiologist use
Y/N
Y/N
Y/N
Y/N
Y/N
PROTOCOL
Justified / Authorised by:
PRIORITY 1
2
3
CONTRAST
AMOUNT
EXPIRY DATE
BATCH No.
INJECTED BY
4
5