NHS COVENTRY & WARWICKSHIRE COMMUNITY IMAGING SERVICE
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 652 4159
Email: GDL.Bookings@nhs.net
Website:www.globaldiagnostics.co.uk
PATIENT DETAILS
Title:
«Title»
DOB:
Address:
Postcode
:
Forename:
«Forename»
«Date_of_birth»
M/F:
«Gender»
«Patient_address_house»
Contact numbers
«Patient_address_road»
Work:
«Patient_alternate_telephone_number»
«Patient_address_locality»
Home:
«Patient_home_telephone_number»
«Patient_address_post_town»
«Patient_address_county»
Mobile:
«Patient_mobile_telephone_number»
«Patient_post_code»
NHS No:
«NHS_number»
Examination required:
Surname:
«Surname»
Ultrasound/MRI
Area to be examined/scanned
Clinical information:
LMP
date:
Or to the best of my knowledge I am not pregnant
Sign:
Referring clinician:
Signature:
«Sender_name»
Address:
Date:
Tel No:
«Todays_date»
«Sender_telephone_number»
Email:
Fax No:
Date:
«Sender_organisation_name»
«Sender_address_road»
«Sender_address_locality»
«Sender_address_post_town»
«Sender_address_county»
«Sender_post_code»
«Sender_fax»
For clinic use:
Justified:
No.of exposures:
Authorised:
DAP:
Time of examination:
Operator:
Radiographer/Ultrasonographer:
Date:
NHS Coventry & Warwickshire Ultrasound Referral Form SystmOne
November 2011