IMAGING REQUEST FORM
Medical Imaging Department,
X-ray Department
Level C, Nightingale Wing,
Andover War Memorial Hospital
Royal Hampshire County Hospital,
Charlton Road
Romsey Road, Winchester, Hampshire SO22 5DG
SP10 3LB
Telephone:- 01962 825013 Fax: 01962 824816
For any changes to opening times of the walk in service for general x-rays please
telephone 01962 825005 for a recorded message
Received……………………
Appt. date…………………
Time…………………………
Room…………………………
Priority
Red dot
Initials
Preparation……………………………
INCOMPLETE OR ILLEGIBLE FORMS WILL NOT BE ACTIONED [IR(ME)R 2000]
Surname: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Forename: . . . . . . . . . . . . . . . . . . . . . . . . Sex: M/F
DoB:
LMP:
Address:
Patient category ( please tick)
NHS
CATll
PP
Mobility
Walking Wheelchair Transport
Ambulance
Hoist required
NHS No:
Infection risk …………………………
Diabetic? ………………………………
Known allergies…………………………
Tel: . . . . . . . . . . . . . . . . . Mobile no: . . . . . . . . . . . . . . . . . . . .
Email address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical indications:
Practice stamp
Examination required [Refer to local and RCR guidelines, IR(ME)R 2000]
Copy report to:-
Referring Consultant or GP
AUTHORISED SIGNATURES ONLY [IR(ME)R 2000]
Signed……………………………………………………………………………
Date………………………………
Signatory name (block caps)
Contact Tel. No. . . . . . . . . . . . . . . . . . . . . . .
Hospital Dept……………………………
An appointment is not necessary for general x-rays (chest, limbs, spine , hips etc) as we operate a walk in service at both
Winchester and Andover.
All scans (MRI/CT and Ultrasound) will need an appointment for which patients will be contacted .
ROYAL HAMPSHIRE COUNTY HOSPITAL MEDICAL IMAGING (X-RAY) DEPARTMENT OPENING TIMES
Monday – Friday 9.00 am – 4.00 pm Excluding Bank Holidays.
In the event of an equipment failure or planned service to equipment we may have to limit this service temporarily. We
have a recorded message giving details of any disruption to service and you may wish to telephone before attending to
check availability.
(24 Hour recorded message) 01962 825005
ANDOVER WAR MEMORIAL HOSPITAL X-RAY DEPARTMENT OPENING TIMES
Monday – Friday 9.00 am – 12 Noon 2.00 pm – 4 pm Excluding Bank Holidays.
At Andover there is only 1 x-ray room therefore the service would be unavailable in the event of an equipment breakdown
or during a planned service.
Information on any disruption to service will be available on the recorded message (available 24hrs) on:- 01962 825005
Hampshire Hospitals NHS Foundation Trust includes Chairman: Elizabeth Padmore
Andover War Memorial Hospital, Basingstoke and North Hampshire Hospital
and Royal Hampshire County Hospital
www.hampshirehospitals.nhs.uk
Chief Executive: Mary Edwards