Department of Clinical Radiology. University Hospitals Bristol NHS Foundation Trust
RADIOLOGY REQUESTS
GP REFERRALS
Referrers are required to complete sections 1-6 accurately and legibly. Inadequately completed forms will not be accepted.
1. Patient ID Radiology Dept Use
Hosp No. NHS No. Appointment: Date: Time:
Surname
Forename(s) Patient ID Confirmed:
Address Operator Signature
2. Patient Mobility / Referral Details
Postcode Transport Type Escort Y / N
DoB GP Name / Practice / Code
Pt daytime contact nos.
3. Clinical details (You are legally obliged under IR(ME)R 2000 to supply sufficient medical data for justification purposes. You MUST provide Radiology with clinical details to enable appropriate investigation and accurate report. Any relevant previous radiological examinations, surgery, radiotherapy and/or chemotherapy to be included)
Clinical Question to be Answered:
Bowel Prep Authorisation for Bowel Examinations:
following explanation with patient by referrer on safe use of bowel cleansing solution.
Picolax ® Klean Prep®
4. Examination Requested: Priority: Urgent Soon Routine
5. Cautions (if none tick here) Possibility of Pregnancy Yes / No LMP
Allergy / severe asthma ? renal impairment Diabetes
Previous Colorectal Surgery MI within last 6wks
Infection Risk to staff/other Patients MRSA IVDU Other please specify
Other considerations (deaf, blind etc)
6. Referrer (print name)
Signature: Contact No.
Date of Request Copy Report to:
For operator/practitioner use only
Examination/procedure authorised by Date
(Subject to decision following check on pregnancy status, if relevant)
Radiologist Instructions:
PLEASE PRESENT WITHIN 1 MONTH (CHILDREN 2WEEKS)
Open Access (Plain film imaging)
Attendance Times (Mon – Fri Exc. Bank Hols) Request MUST be available via ICE
Adult GP Referrals (No Children under 16yrs)
South Bristol NHS Community Hospital,
Hengrove Promenade, Bristol BS14 0DE. Tel: 0117 342 9696
Open Access Monday – Friday 9:00am – 5:00pm
Weekend Appointments 9:00am – 5:00pm SBCH Only
Contact the X-Ray Department on 0117 342 9696 during the following times to book an appointment
4:00pm – 7:30pm Monday to Friday or 8:00am – 6:00pm Saturday and Sunday
Bristol Royal Infirmary – Location A217
Marlborough Street, Bristol, BS2 8HW. Tel: 0117 342 2638
Open Access Monday – Friday 9:00am – 4:00pm
High dependency patients must attend Bristol Royal Infirmary
9am – 4pm Tel: 0117 342 2638 Drop off point at entrance.
Requests for Mandible/Temporo-mandibular Joints
Please attend Bristol Dental Hospital or Bristol Royal Infirmary
Children (Under 16yrs)
Must attend Bristol Children’s Hospital Marlborough Street, Bristol. (Accompanied by an Adult)
9:30am – 11:30am 2:00pm – 4:00pm Tel. 0117 342 8186
Obs & Gynae Requests to be directed to St Michael’s Hospital, Southwell Street, Bristol 0117 342 5347
Bus services serving Hengrove Park
First services 36, 50, 51, 75, 76, 515 serve Hengrove Park. (In addition, ABUS service 52 operates within ½ mile of the site).
As far as I am aware I am Not Pregnant
Patient Signature:
Radiographer Signature:
Examination Comments: Uneventful Procedure
PLEASE PRESENT WITHIN 1 MONTH (CHILDREN 2WEEKS)
Issue Oct 2014 SK/KH