Imaging Referral Form Imaging Referral form for localised imaging services. Imaging Modality * MRI CT USS Plain Film X-Ray Number of Areas (Parts) * 1 Parts 2 Parts 3 Parts Preferred Appointment Date * MM DD YYYY Preferred Appointment Time * Appointment will be confirmed to you by the provider. Hour Minute Second AM PM Team Doctor/Head of Medical Name * First Name Last Name Team Doctor/Head of Medical Telephone * Country (###) ### #### Team Doctor/Head of Medical Email * Patient/Player Name * First Name Last Name Patient/Player Date of Birth * MM DD YYYY Patient Area(s) to be scanned * Medical Information - Does the patient have? * Please tick for yes A cardiac pacemaker? Any surgery on heart, head or spine? Other metal implants? Neurostimulator? Programmable hydrocephalus shunt? Metallic foreign body in eye (ever)? Cochlear implant? Other surgery in the last three months? Could the patient be pregnant? Is the patient breast feeding? Does the patient have any allergies? Is the patient an infection risk (e.g. MRSA)? Is the patient diabetic? None of the above? If you have said yes to any of the above (apart from none) please give details: If a foreign body in the eye, please state date of x-ray: MM DD YYYY Clinical History and Indications for the examination and clinical question to be answered? * For comparison reporting prior images and reports will need to be provided in advance of the patients appointment. please state date, location, and type of relevant previous investigations: Referrer Name: * First Name Last Name Referrers Declaration: I have discussed the examination with the patient and considered the the contradictions as detailed above: * Yes No Date of Referral * MM DD YYYY GMC/HCPC Number or equivalent: * CT and X-Ray ONLY : I am IRMER certified and am able to referrer the patient for these diagnostic procedures Yes No - Needs Clinical Review As the referring clinician I accept the following: * I have fully discussed this appointment with the patient. To the best of my clinical knowledge believe that this examination and diagnostic image is the best medical intervention for my patient. I agree to accept this as an electronic signature for the referral into the diagnostic imaging service. Electronic Signature * By entering my name below I certify the above to be correct and to the best of my knowledge true and accurate. Confirm Email Address to receive report and Images. * Thank you for submitting your referral form for diagnostic imaging. The local provider will confirm with you your appointment time and date. Please do not attend until you have had confirmation. Payment will be taken upon arrival.
