Services for doctors at Harley Street Specialist Hospital

Refer A Scan Or Image Guided Injection

PATIENT DETIALS

Full name(Required)

Title First Last

Date of birth(Required)

Sex(Required)

Mobile

Telephone(Required)

Email(Required)

Address(Required)

Address Line 1 Address Line 2 City Postcode

Billing(Required)

Insurer(Required)

Policy No(Required)

Pre-Auth. No(Required)

Preferred Date(Required)

Preferred Time(Required)

To be reported by

Examination Requested(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?

History of intra-orbital fb(Required)

Pregnancy(Required)

Pacemaker(Required)

Recent Surgery(Required)

Intercranial clips(Required)

Diabetic on Metformin(Required)

Prosthetic heart valve(Required)

Asthmatic or allergic to contrast(Required)

Cochlear implants(Required)

Other allergies(Required)

Any kidney problems/dialysis(Required)

Taking anticoagulants/ antiplatelet drugs e.g. Warfarin(Required)

Serum creatinine/Estimated GFR:(Required)

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

Age over 65(Required)

Severe claustrophobia(Required)

Heart Conditions(Required)

Pregnancy(Required)

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

Referred by(Required)

GMC Number(Required)

Contact number(Required)

Date(Required)

Signature(Required)

Radiographer Checklist

Checklist

Correct Patient

Correct Side/Procedure

‘Pause and checked’

Pregnancy check

Date

Time

Dose (MGY)

Radiographer

Notes