Direct Access Non-Obstetric Ultrasound and MRI Request Form
Date of Referral:
Patient Details:
Name (First & Surname)
D.O.B:
NHS No.
Address:
(NB age ≥ 18 years)
Home Tel No:
Mobile Tel No:
Gender:
Please select
Physical/Communication Difficulties
(Please specify i.e. wheelchair user):
Referrer Details:
Name:
Address:
UBRN No:
Postcode:
GP Practice Code / CCG:
Tel No:
Fax No:
E-mail:
(Please include your E-mail address if you would like to receive
an electronically transmitted report).
Ethnic Origin:
If Interpreter required, please specify
language:
Please select
Chaperone required (ultrasound only):
Please select
SCAN REQUEST
prior to referral)
(Referrers should ensure any local care pathways/primary care options have been followed
Ultrasound (excludes referrals for breast, obstetric,
cardiac imaging, chest, ophthalmology, superficial
lumps in the neck, axilla or groin and thyroid)
Please indicate type of ultrasound required.
Upper Abdomen
TV/TA Female Pelvis
(+/- Kidneys)
Renal Tract
TV/TA Female Pelvis
(+ Upper Abdomen)
MSK (No Necks)
Female Pelvis only
Aorta
Groin / Male Pelvis
Vascula (Includes
Testes
suspected DVT)
Please select:
URGENT
ROUTINE
Clinical Condition / Symptoms and Clinical Indication
(including relevant previous medical and drug history. Please
include patient’s BMI)
MRI (without contrast) Knee, Head and Spine
Please state body area to be scanned. If knee state L or R;
for spine please state if cervical, thoracic or lumbar.
Clinical question to be answered by the scan
MRI Contraindications Does the patient have or has ever had one of the following (please indicate as appropriate)
Pacemaker
Please select
Impl. Cardiovert. Defib.
Please select
Aneurysm Clips
Please select
Heart Valve Prosthesis**
Please select
Neurostimulator
Please select
Cochlear Implant
Please select
Metallic IOFB*
Please select
Shunts or Stents
Please select
Implantable Pump
Please select
Patient Pregnant?
Please select
* If Metallic IOFB indicated, a report from orbit x-ray is required with referral.
** If Heart Valve Prosthesis indicated, make, model and serial number may be requested to determine MRI compatibility.
Patients in the first trimester of pregnancy are
Previous Imaging (please indicate as appropriate)
contraindicated. Following this time scanning must be CT
Please select
MRI
Please select
discussed with a Radiologist.
Ultrasound Please select
Signature (if manual submission):
GP GMC No:
When & Where undertaken.
(Copy of report is required with referral)
Name (Printed):