BRIC MRI scan request

·  All fields mandatory (except those in italics).

·  Incomplete forms will not be processed; scans will be cancelled.

·  Type details onto this form.

·  Shaded boxes will be completed by BRIC Admin office: DO NOT AMEND

·  Email completed form to:

WTCRF study number (E number): / E151483
BRIC short title of study: / PREDICTRA / Initial box below once report sent
Send clinical radiology report to: / GP
Name of principle investigator (PI): / Dr McKay
REQUESTOR INFORMATION
Requested by:
Contact number:
Contact e-mail:
Desired date/time of scan: (dd/mm/yyyy) and (hh:mm)
SUBJECT DETAILS
- must be in SBIRC at least 1 working day prior to scan or any booked slot will be cancelled
Subject study reference number:
- if available
Surname:
Previous surname (if known):
Forename:
Date of birth:
CHI number:
Previous address:
- if subject moved recently / Current address:
Current telephone number:
Study team confirmation of subject written consent (tick to confirm)
FAMILY DOCTOR INFORMATION / (space for notes)
Name and address:
MR SCREENING: Indicate if the subject has one or more of the following:
Cardiac Pacemaker * / YES NO
Intracranial surgery / aneurysm clip * / YES NO
Abdominal surgery / stents * / YES NO
Ferrous metal in the body / orbits * / YES NO
History of Renal Impairment / YES NO

* To confirm safety of implants contact Radiographers on 0131 537 2660

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