Centre for Perinatal Neuroscience
MRI AND MR SPECTROSCOPY REQUEST FORM
Hospital Number: Click here to enter text.
NHS Number: Click here to enter text.
Patients Name:
DOB:
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Requesting Consultant: Click here
Date of request: Click
to enter text.
here to enter text.
Gestation at birth:
Current gestation: Click
Current weight:
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GP (name and address):
Parents contact details: (phone/mobile)
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Indication for the MR scan:
☐ Clinical
☐ Research
Referral pathway
In-patient other hosp:
☐ QCCH in-patient
☐ Outpatient/Home
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☐ SMH in-patient
☐ Fetal MRI
Body part
Other (specify):
☐ Brain
☐ Whole Body
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☐ Fetal MRI
☐ Cardiac
Request type
☐ Urgent (<24 h)
MR spectroscopy report required
☐ Semi-Urgent
☐ Yes
☐ Elective
☐ No
Metal implants/PDA clips/Pacemaker (please attach a
☐ Yes
☐ No
☐ Yes
☐ No
scanned copy of the device details)
Have parents consented for sedation for the MR
scan (in case of a newborn)
Relevant Medical History:
Cranial US or Antenatal US findings:
Reason for requesting the MR scan:
Current status: For neonatal scans only (cross the relevant box by pressing the space bar, with cursor near the box)
Respiratory
☐ None
☐ Low flow oxygen
☐ nCPAP/High flow*
☐ Ventilated*
support
The Consultant requesting the MR should discuss any baby requiring respiratory support with Dr Sudhin Thayyil
(07912 888 700) before an MR date is given. An MR trained neonatal consultant will supervise all such scans*.
Infusions
☐ Dextrose (± additives)
☐ Sedation
☐ Other, specify
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Feeds/Fluids
☐ Breast/bottle
☐ Nasogastric tube
☐ Intravenous fluids
IV access
☐ Long line
☐ UAC/UVC
☐ No
☐ Peripheral line
☐ None
Recent infection
☐ Inotropes
☐ Yes (give details):
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Medications
CPN to complete (please leave blank)
Date of MRI:
Team required (To be agreed beforehand by Dr Thayyil):
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Doctor 1: Click here to enter text.
Problems during MRI if any
Doctor 2: Click here to enter text.
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Nurse: Click here to enter text.
Radiographer/MR Physicist: Click here to enter text.
Please complete this form in full and e-mail to ICHC-tr.cpn@nhs.net and copy to s.thayyil@nhs.net and
MR Study Number:
belinda.smith@imperial.nhs.uk For urgent requests please contact: 0774 173 8336
or 07912 888 700.
All MR reports will be in PACS within 3 days of the scan. It is the responsibility of the referring clinician to inform the parents about the scan results,
in case of a clinical MR scan. In neonatal encephalopathy cases, an MR spectroscopy report will be send to the referring clinician after postprocessing of the spectra using LC Model. Please do not use the MRS metabolite ratios values in PACS.
CPN MRI request form Version 5 (4.12.2015)