GP Imaging Referral
PATIENT DETAILS
REFERRING CLINICIAN ( Doctor only)
Name:
Address:
Name:
Post code
Address:
Date of birth:
Telephone:
_________________(home)___________________ (mobile)
Gender:
Male
Female
Eligible for transport:
Yes
No
Transport required:
Yes
No
Post code:
Telephone:
Fax Number:
If Interpreter required, language? ___________________________
Religion:
________________________________________
Ethnicity:
________________________________________
INVESTIGATION REQUIRED
Knee
ULTRASOUND
XRAY
Hip
ULTRASOUND
XRAY
MRI (COMPLETE SECTION BELOW)
ULTRASOUND ONLY
Elbow
Hand / Wrist
Foot/ Ankle
Soft Tissue / Lump
Other (Please specify)
_____________________________________________
Shoulder - Please note: For Ultrasound requests of the shoulder please use the separate dedicated referral form.
CLINICAL INDICATIONS
(Referral should be made in line with The Royal College of Radiologists Imaging Referral Guidelines)
Is there any possibility of the patient being pregnant? Yes
No
Date of last menstrual period (dd/mm/yyyy)
Patient Allergies _________________________________________________________________________________________________________________
Is the patient:
Diabetic
YES
Patient on Warfarin
NO
YES
NO
MRI KNEE REFERRALS ONLY
R
L
Suspected Meniscal Tear
Other reason (specify)
Suspected Ligament Damage
Locked Knee Pain
__________________________________________________
________________________________________________________
DO NOT Refer your patient for MRI if they have the following absolute contraindications:
A Pacemaker
YES
NO
Cochlear Implants
YES
NO
Aneurysm Clips
YES
NO
Neuro Stimulator
YES
NO
Programmable Hydrocephalus Shunt
YES
NO
Proven Intra-orbital Metallic foreign Body YES
NO
Contraindications that need investigating prior to MRI scan (Please detail):
Cardiac Stent /any other Heart Surgery
YES
NO
___________________________________________________________________________
Intrauterine Device
YES
NO
___________________________________________________________________________
Other implant or device
YES
NO
___________________________________________________________________________
Referrer’s Signature
Date of request
Please post or fax this form to:
Imaging Department, Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, B31 2AP
Telephone: 0121 685 4135
Fax: 0121 6854108
Email: roh.mskultrasound@nhs.net
OFFICE USE ONLY
Date received: _______________
Fax Number: 0121-6854134
Rejected
DNA
email: ROH.MSKULTRASOUND@NHS.NET
Cancelled
Coments: ________________________________________
Appointment Date: ________________Time:___________
Examining Radiographer: ___________________________