Direct access non-obstetric ultrasound request form
Patient details
Surname:
First Name:
D.O.B.
/
NHS no:
Address:
GP details*
Name:
GMC No:
/
Practice Code:
Surgery:
Tel:
E-mail:
Post code:
Tel No.:
Mobile No:
*Shaded items compulsory
Ultrasound Scan Request (please select scan(s) required)
Abdomen
CLINICAL INFORMATION
Relevant history, examination, investigations
Diabetic
Y
N
Interpreter
Y
required
N
Severely
impaired
mobility
N
Renal Tract
Pelvis (male or female)
Aorta
Y
Scrotum
Musculoskeletal
Superficial mass
NOT neck/groin/axilla
Neck
Groin/axilla
Vascular
Other (please specify)
ROUTINE
URGENT
Signature
(Delete as
appropriate)
What information do you require from this examination?
Is the patient to be considered at the same time for an
ultrasound-guided injection or other procedure?
Y
N
Has previous imaging (X-ray/US/CT/MRI) been performed
for the same problem? (please specify above)
Y
N
Name Printed
Date
Please refer to the RMS website for more detailed information regarding ultrasound scans