IMAGING REQUEST FORM
Medical Imaging Department, X-ray Department
Level C, Nightingale Wing, Andover War Memorial Hospital
Royal Hampshire County Hospital, Charlton Road
Romsey Road, Winchester, Hampshire SO22 5DG SP10 3LB
Telephone:- 01962 825013 Fax: 01962 824816
For any changes to opening times of the walk in service for general x-rays please telephone 01962 825005 for a recorded message
INCOMPLETE OR ILLEGIBLE FORMS WILL NOT BE ACTIONED [IR(ME)R 2000]Surname: ...... Forename: ...... Sex: M/F
DoB: LMP:
Address:
NHS No: Tel: ...... Mobile no: ......
Email address: ......
Clinical indications:
Examination required [Refer to local and RCR guidelines, IR(ME)R 2000]
AUTHORISED SIGNATURES ONLY [IR(ME)R 2000]
Signed…………………………………………………………………………… Date………………………………
Signatory name (block caps) Contact Tel. No......
Received……………………
Appt. date…………………
Time…………………………
Room…………………………
Priority Initials
Preparation……………………………
Patient category ( please tick)NHS CATll PP
Mobility
Walking Wheelchair Transport
Ambulance Hoist required
Infection risk …………………………
Diabetic? ………………………………
Known allergies…………………………
Practice stamp
Copy report to:-
Referring Consultant or GP
Hospital Dept……………………………
Hampshire Hospitals NHS Foundation Trust includes Chairman: Elizabeth Padmore
Andover War Memorial Hospital, Basingstoke and North Hampshire Hospital Chief Executive: Mary Edwards
and Royal Hampshire County Hospital
www.hampshirehospitals.nhs.uk
An appointment is not necessary for general x-rays (chest, limbs, spine , hips etc) as we operate a walk in service at both Winchester and Andover.
All scans (MRI/CT and Ultrasound) will need an appointment for which patients will be contacted.
ROYAL HAMPSHIRE COUNTY HOSPITAL MEDICAL IMAGING (X-RAY) DEPARTMENT OPENING TIMES
Monday – Friday 9.00 am – 4.00 pm Excluding Bank Holidays.
In the event of an equipment failure or planned service to equipment we may have to limit this service temporarily. We have a recorded message giving details of any disruption to service and you may wish to telephone before attending to check availability. (24 Hour recorded message) 01962 825005
ANDOVER WAR MEMORIAL HOSPITAL X-RAY DEPARTMENT OPENING TIMES
Monday – Friday 9.00 am – 12 Noon 2.00 pm – 4 pm Excluding Bank Holidays.
At Andover there is only 1 x-ray room therefore the service would be unavailable in the event of an equipment breakdown or during a planned service.
Information on any disruption to service will be available on the recorded message (available 24hrs) on:- 01962 825005
Hampshire Hospitals NHS Foundation Trust includes Chairman: Elizabeth Padmore
Andover War Memorial Hospital, Basingstoke and North Hampshire Hospital Chief Executive: Mary Edwards
and Royal Hampshire County Hospital
www.hampshirehospitals.nhs.uk