Bexley CCG
MRI REFERRAL FORM (Non Contrast)
Please note – we are unable to accept referrals for patients under 18 years of age
Please note – we are unable to accept referrals for breast MRI
PATIENT	REFERRER	
NHS Number	~[NHS Number]	Name	~[Free Text:Referring GP Fullname]	
Forename	~[Forename]	GMC/HPC/NMC No	     	
Surname	~[Surname]	Address	~[Surgery Address Line 1]
~[Surgery Address Line 2]
~[Surgery Address Line 3]
~[Surgery Address Line 4]
~[Surgery Address Line 5]	
Address	~[Patient Address Block]
~[Post Code]			
Date of Birth	~[Date Of Birth]	Referring CCG Code	     	
Telephone (Home)	~[Telephone Number]      	Referring Practice Code	     	
Telephone (Work)	     	Telephone No.         
(for urgent clinical findings)	~[Surgery Tel No.]	
Telephone (Mobile)	~[Mobile Phone Number]      	Fax No.	     	
E-mail Address	     	NHS.net mail only	     	
Gender	~[Sex]	If interpreter required, please specify language:
	
Physical/Communication difficulties (specify if any):
     	Height:                                Weight:	
		
Ethnicity: ~[Ethnicity]		

PRESENTING COMPLAINT & PROVISIONAL DIAGNOSIS
Please provide as much relevant clinical information as possible to assist with the interpretation of the referral and images.

What is the patient's presenting complaint?

How long has this complaint been persisting?

What treatment/management of the condition has been provided?

What is the clinical question you require us to answer?

Please tick box if this scan is related to recent (within 5 years) spinal or neurosurgery 	
Investigation(s) Required: tick investigation required; please indicate which side of body and body part where appropriate.
	
Brain		Foot	L     R	Renal angiogram	
	
IAMS (both)		Ankle	L     R	Mortons Neuroma	
L   R
	
Pituitary Fossa		Shoulder	L     R	Abdomen – Liver, Kidneys & adrenals	
	
Cervical spine		Knee	L     R	MRCP	
	
Thoracic spine		Hips	L     R	Other contrast enhanced scan (state):

            

	
Lumbar spine		Sacroiliac Joints		Other (state body part and body side):     

      	
All referrers must complete the following MRI safety questions:
Does the patient have any implanted metallic foreign devices? (e.g. cardiac pacemaker, artificial heart valve, cerebral aneurysm clips, cochlear implant etc)

Is the patient known to have metallic fragments in their eyes?
Date of Referral ~[Today...]	Yes      No  

Yes      No  	

Please post, fax or e-mail this form to the InHealth Patient Referral Centre
Sandbrook House, Sandbrook Way, Rochdale, Lancashire OL11 1RY
Tel: 0333 202 0297 Fax: 0333 200 1163 E-mail: london.prc@nhs.net
	
www.inhealthgroup.com

Version: EMIS LV July 2016