Imaging Request - Candover Cliniccandoverclinic.com/.../05/Candover-Imaging-Request-Form.docx ·...
Transcript of Imaging Request - Candover Cliniccandoverclinic.com/.../05/Candover-Imaging-Request-Form.docx ·...
Candover Clinic Imaging Request Form
semper speravitPatient details Referrer Details
Surname:
First Name:
DOB:
Patient Address:
Post code:
Home Telephone Number :
Mobile Telephone Number:
Registered GP:
Referring GP / Consultant:
Send report to :
Tel Number(s):
Email:
Examination requested: Known Allergies:
Clinical Indications:
Referrer DeclarationThis is a legal document.The correct patients’ details have been given.I have discussed the examination with the patient/ guardian.I have provided sufficient clinical information for the request to be justified according to IR(ME)R 2000.I will ensure the results are recorded in the patients’ notes.
Referrer’s Signature: Date:
Print Name:
MRI disclaimerIf you have any of the following;
A cardiac (heart) pacemaker ● Aneurysm clips in your brain A cochlear implant ● A neuro stimulator Or any other medical devices
We may not be able to scan you. Please contact the MRI department before your appointment.
Candover Clinic Hampshire Hospitals NHS Foundation Trust
Telephone: 01256 315010/315011 - Facsimile: 01256 315033candoverclinic.com
Candover Clinic Imaging Request Form
semper speravitPLEASE RETURN THE SIGNED FORM BY FAX - 01256 315033
Candover Clinic Hampshire Hospitals NHS Foundation Trust
Telephone: 01256 315010/315011 - Facsimile: 01256 315033candoverclinic.com