Team Doctor/Head of Medical Name *

First Name

Last Name

Team Doctor/Head of Medical Telephone *

Country

(###)

###

####

Patient/Player Name *

First Name

Last Name

Patient/Player Date of Birth *

MM

DD

YYYY

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?

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

I am IRMER (or equivalent) 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.