St. Helens and Knowsley Teaching Hospitals

MR IMAGING REQUEST FORM

MRI Department, Whiston Hospital, Warrington Road, Prescot, Merseyside

Tel: 0151 430 1233 Fax: 0151 430 1843

Patient's details (or affix ID label)
Name......
Address......
......
Postcode...... Tel......
DOB...... Hosp.No......
NHS No...... /
Ward/Dept...... Date......
Consultant/GP......
Signature......
Print name......
Designation...... Bleep No......
Please complete the form fully. Failure to do so will delay booking and may affect patient safety

Walking / Chair / Trolley / Bed / TRANSPORT DETAILS
Ambulance yes / no Escort yes / no
Clinical details
Area to be examined: Known infection risk
E.g. MRSA, HepB or HIV
Previous imaging?
Priority (Please tick)
Relevant clinical history: Including any previous surgery Routine Semi-urgent Urgent

Appointment details
What is the clinical question?
Referrer’s Declaration: If the answer is yes to any of the following then MR may be contraindicated:
(MUST BE COMPLETED WITH THE PATIENT)
CARDIAC PACEMAKER Y/N
INTRACRANIAL VESSEL CLIPS Y/N
ARTIFICIAL HEART VALVE/STENTS Y/N
INTRA ORBITAL FOREIGN BODY Y/N
1st TRIMESTER PREGNANCY Y/N
ANY INTERNAL MECHANICAL DEVICES Y/N
PATIENT HEIGHT
PATIENT WEIGHT
Signed……………………………………………… / For radiologist use
PRIORITY 1 2 3 4 5
PROTOCOL

Comments:

Magnetic Resonance Safety Screening Form

(To be completed by MRI staff ONLY with the patient present)

·  Have you a heart pacemaker or artificial heart valve? Yes /No

·  Have you any aneurysm clips, cochlear implant or a shunt Yes / No

in your head?

·  Have you had surgery within the last 6 weeks Yes /No

·  Have you ever had any metal fragments e.g. shrapnel in Yes /No

any part of your body?

·  Have you ever had any metal splinters in your eyes? Yes /No

·  Have you ever had a joint replacement or had a bone

Injury/condition treated with screws, plates or rods? Yes /No

·  Do you were dentures or a hearing aid? Yes /No

·  Do you suffer from epilepsy or diabetes? Yes /No

·  Have you removed all loose metallic objects e.g. watch, wallet

Keys, hair clips, mobile phone and bankcards? Yes /No

·  Have you any internal metal whatsoever? Yes /No

·  Please state your weight in …………………………kgs/stones

To be answered by ladies of child bearing capacity age: -

·  Is there any possibility that you may be pregnant? Yes /No

·  Are you breastfeeding at the moment? Yes /No

I have answered and understood the above screening questions

Signature ……………………………………………

Print name…………………………………………..

Verified by……………………………………Date……………………..

Supervising MR radiographer………………………………………………