NHS e-Referral Service
Imaging Service request form
SECTION 1: PATIENT DEMOGRAPHIC DETAILS
Patient NHS number:
UBRN:
Patient first names:
Patient last name:
Date of Birth (DD/MM/YY):
Gender:
Male
st
Patient address (1 line):
Patient town / city:
Patient postcode:
Patient contact number:
Patient contact number 2:
SECTION 2: REFERRER INFORMATION
Referrer first name:
Referrer last name:
Referrer role:
GP
Other, Please specify:
GP Practice Code:
Referrer contact no:
GMC Registration No:
Referrer e-mail address:
SECTION 3: IMAGING SERVICE REQUEST
Imaging procedure requested (include left / right where relevant)
Referral date:
Priority:
Routine
Urgent
Provisional diagnosis (or key symptoms and signs):
Clinical question to be answered, relevant clinical history and previous imaging: (if available attach imaging results)
N.B. The referrer must provide sufficient clinical information to justify the request.
SECTION 4: CLINICAL SAFETY QUESTIONS
If you answer ‘Yes’ to any of the questions, please ensure that you include any relevant clinical information above.
Does the patient present a communicable infection risk?
No
Yes
Is the patient known to be pregnant?
No
Yes
Has the patient had a previous allergic reaction to contrast?
No
Yes
Is the patient known to have renal impairment?
No
Yes
Is the patient at risk from cardiac failure?
No
Yes
Is the patient on Metformin ?
No
Yes
Does the patient have asthma?
No
Yes
Does the patient have any implanted metallic foreign devices? (e.g. cardiac pacemaker,
artificial heart valve, cerebral aneurysm clips, cochlear implant, etc.)
No
Yes
Is the patient known to have metallic fragments in their eyes?
No
Yes
Is the patient known to suffer from severe claustrophobia?
No
Yes
Is the patient known to have renal impairment?
No
Yes
COMPLETE FOR ALL CT AND IVU REQUESTS
COMPLETE FOR ALL MRI REQUESTS
COMPLETE FOR ALL OBSTETRIC ULTRASOUND REQUESTS
Parity:
Gravida:
Date of LMP or number of weeks pregnant:
Female