Referring clinican:
Referrer Name: / Date of Referral:
Referring Practice: / Tel Number:
Practice Address:
Postcode: / Fax Number:
Patient details:
Name: / NHS Number:
Date of Birth: / Gender: Male Female
Address:
Postcode: / Tel Number:
Mobile Number:
Interpreter Required: Yes / No
If interpreter required which language:
Ethnic Origin:
Pregnancy status: Not Pregnant / Pregnant
LMP: / If yes: Gestation weeks:
Service specific referral information:
Examination Requested including area to be imaged:
Relevant Clinical Information: (as examination is protocol based, the quality of this information is important:
Provisional Diagnosis:
State any known allergies, especially to Radiographic contrast media (including the type of reaction if known):
Authorised by signature of referring clinician):
for internal use only:
Radiologist:
Priority: Routine: Urgent:
Appointment date:
Appointment time: / Room:
FOR YOUR INFORMATION
X-ray Department / X-ray Department / Evelina London Children’s HospitalSt Thomas Hospital / Guys Hospital / St Thomas’ Hospital
1st Floor Lambeth Wing / 2nd Floor Tower Wing / Children’s Imaging, Arctic Floor
Westminster Bridge Road, SE1 7EH / Great Maze Pond SE1 9RT / Lambeth Palace Road, London, SE1 7EH
Tel No . 020-718 85490 / Tel No. 020-7188 5527 / Tel: 0207 188 9218
Fax No. 020-7-261 0405
Appointments 020-718-85542 / Fax No. 020-7188 5523
Appointments 020-718-85542 / Fax number 020 7188 5202
Appointment 0207 7188 9218
The following tests require an appointment.
IVU, Ultrasound, Barium /Swallow/Meal/Enema./MRI/CT
To obtain an Appointment please send this form to the address of your nearest hospital given above. Please make sure your Full Address and Telephone No. is clearly printed on the form.
All other general x rays are performed on a ‘walk in’ basis at either:
-Guys hospital in the main X-ray Dept located on the 2nd Floor Tower Wing. Opening hours are from 8.30am-5pm Monday to Friday
Or at
-St Thomas Hospital, the main X-ray Dept, located on the 1st floor Lambeth Wing. Opening hours are from 8:30am-5pm Monday to Friday
Or at
-Evelina Children’s Hospital, the main X-ray Dept located on the Children’s Imaging, Arctic Floor. Opening hours are from 9:00am -5 pm
Monday to Friday. Full address and telephone numbers detailed above
If you need an interpreter please advise your GP
The results of your examination will be sent to your GP and should be available in 7 -10 days. Please make arrangements with your GP practice to be informed about your results.
To help us decide if you are entitled to free NHS care, you are requested to bring proof of identity and a proof of address with you. If you are not entitled to free NHS care, you will be asked to pay for your treatment.
CAR PARKING FACILTIES ARE VERY RESTRICTED PLEASE USE PUBLIC TRANSPORT WHEREEVER POSSIBLE.
Guy’s Hospital is situated near London Bridge Station
St Thomas Hospital is situated near Waterloo Station and Westminster Bridge.
(2) Form 1056