NHS Diagnostic Service

MRI REQUEST FORM

PLEASE NOTE-WE ARE UNABLE TO ACCEPT REFERRALS FOR PATIENTS UNDER 18 YEARS OF AGE

Patient ID / Referring Clinician
NHS number: / Name:
Name: / Qualifications:
GMC/HPC No:
Address: / Referring PCT Code
Referring Practice Code:
Address:
Post code
Date of birth:
Telephone: / (home) / Post code:
(work) / Urgent Telephone*
(mobile) / Fax:*
Email: / *for clinical enquiries use only
Gender: / NHS mail:
Eligible for transport / Yes No / Clinical specialty:
Transport requested: / Yes No
Physical/communication difficulties (specify if any)
If interpreter required, language?
Religion:
Ethnicity:
Investigation Required & Provisional Diagnosis
Lumbar Spine / Radiculopathy (indicate side) with neurological deficit that has not responded to conservative treatment or is demonstrating severe and progressive motor loss
Other reason (specify)
Knee / Suspected meniscal tear
R L / Suspected ligament damage
Knee pain where arthroscopy considered
Other reason (specify)
Shoulder / Impingement
R L / Instability
Rotator cuff wear
Other reason (specify)
Head / Persistent headaches
Other reason (specify)
Other area (specify)
All clinicians must complete the following MRI Safety Questionnaire / Yes / No
1.  Does the patient have any implanted metallic foreign devices? (e.g. cardiac pacemaker, artificial heart valve cerebral aneurysm clips, cochlear implant etc)
2.  Is the patient known to have metallic fragments in their eyes?
3.  Is the patient known to have renal impairment (eGFR<30)?
4.  Does the patient have any allergies?
5.  Has the patient had any previous surgery?
If yes, please give details:
Is there any possibility of the patient being pregnant? / Yes No
Date of last menstrual period / (dd/mm/yyyy) / Breast feeding? / Yes No
Referrer’s Signature: / Date of request
Please fax or email this form to the InHealth Patient Referral Centre
Email: / www.inhealthgroup.com

PLEASE NOTE-WE ARE UNABLE TO ACCEPT REFERRALS FOR BREAST MRI