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Imaging Request

    This form is for medical professionals only.
    Please complete, and we will call you back shortly to confirm a date.

    Please note* a normal turnaround time for reports is 24 hours, however, urgent reports can be requested and accommodated depending on availability of a radiologist.

    Do you need to request an urgent report? (please tick):

    YesNo

    If you ticked yes, please state the preferred date and time you would need the report by:

    Patient Details

    Examination/Procedure

    Please select procedure(s):

    MRICTX-RayDexaUltrasound

    MRI: Please complete the following safety questions

    Does the patient have a Cardiac pacemaker, cochlear implants, cerebral aneurysm clips?*

    Has the patient had surgery in the last 8 weeks?*

    Does the patient have a history of metallic foreign body to the eye?*

    Is there a possibility of pregnancy/breast feeding?*

    Does the patient have or has had renal impairment? If so we need eGFR score before giving contrast.*

    Provide eGFR score

    Does the patient have a history of allergies?*

    Does the patient have any implants or other foreign bodies in your body e.g. replacement joints, plates, drug pumps, wires, clips or shrapnel?*

    CT: Please complete the following safety questions

    Is there a possibility of pregnancy/breast feeding?*

    Does the patient have or has had renal impairment?* If so we need eGFR score before giving contrast.

    Provide eGFR score

    Does the patient have a history of allergies?*

    Any history of diabetes?*

    Is the patient on metformin or glucophage?*

    For all patients requiring I.V. Contrast

    Has the patient had a contrast injection before? *

    Is the patient likely to have a raised serum creatinine?*

    X-Ray: Please complete the following safety questions

    Is there a possibility of pregnancy? *

    Ultrasound

    There are no safety questions

    For female patients

    Referring Clinicians Details

    How would you like to receive the report (please tick):

    EmailPostFax

    Referrers Declaration

    • The correct details have been provided.
    • I have discussed the examination including any intervention.
    • I have taken into account possibility of pregnancy.
    • I have given sufficient clinical information for the requested to be justified according to IR (ME)R 2000.
    • There are no known contra-indications to performing the requested examination.
    • I will ensure the examination results are recorded in the patient notes.
    • The Ionising Radiation (Medical Exposure) Regulations 2000 require you to complete all this information accurately.
    • I confirm this is my approved signature
    • By sending this e-mail, I am signing this referral electronically. I agree that my electronic signature is the legal equivalent of my manual signature on this referral form and has the same validity. I consent to be legally bound by this Agreement's terms and conditions.