Refer A Scan Or Image Guided Injection

PATIENT DETIALS

Full name(Required)
Date of birth(Required)
Address(Required)
Preferred Date(Required)
Preferred Time(Required)
:

Clinical Indication for the examination

Please summarise relevant history, clinical findings & test results. Indicate the question that the examination should answer. Examinations CANNOT be performed without sufficient relevant clinical information & a Doctor’s signature, in line with Ionising Radiation Medical Exposures Regulations 2017.

Important

If Contrast is required for the scan or MRI: Does the patient have any of the following contraindications?

Referring Consultant/GP - PLEASE COMPLETE ALL THE CONTACT INFORMATION BELOW

Referring Consultant/GP - PLEASE COMPLETE ALL THE CONTACT INFORMATION BELOW

Date(Required)

Radiographer Checklist

Checklist(Required)
Date(Required)
Time(Required)
: