Global Diagnostics Ltd (Head Office)
The Global Clinic Norwich
The Old Pumphouse
Colney Hall, Watton Road
Norwich NR4 7TY
Telephone: 0800 652 4157
Facsimile: 0800 6524159
Email: global.admin@nhs.net
Website: www.globaldiagnostics.co.uk
PATIENT DETAILS
Title:
Surname:
Forename:
DOB:
M/F:
Address:
Contact numbers
Work:
Home:
Mobile:
Postcode:
NHS No:
Examination required:
Ultrasound:
(Please indicate body part to
be scanned)
MRI:
Clinical information:
LMP
date:
Or to the best of my knowledge I am not pregnant
Sign:
Referring clinician:
Signature:
Address:
Date:
Tel No:
For clinic use
Date:
Fax No:
Justified:
No. of exposures:
Date:
Authorised:
DAP:
Time of examination:
Operator:
Radiographer / Ultrasonographer:
Drug:
Amount:
Batch No:
Administration: