ULTRASOUND REFERRAL FORM
Brent – Hammersmith & Fulham – Kensington & Chelsea - Westminster
For Echocardiography, please use the Physiological Measurement Referral Form
We are unable to accept referrals for patients under 16 years of age
We are unable to accept referrals for breast or obstetric ultrasound
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 PCT 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]	Eligible for and does require NHS funded transport?
(car transport only)                         Yes 	
Physical/Communication difficulties (specify if any):
     	Wheelchair user?                              Yes 	
If interpreter required, language:      	The patient must be ambulant, or if a wheelchair user they must be able to transfer independently onto the examination couch.	
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.

     	
Date of Referral: ~[Today...]	
Investigation(s) Required: tick investigation required; please indicate which side of body and body part where appropriate.
	
General Ultrasound Clinic:	Musculoskeletal & Specialist Clinic:	
Vascular Clinic:
	
Abdomen – to include abdominal aorta		Musculoskeletal (specify area):
     	 L     R
   
	Doppler - Carotid Arteries		
Abdomen & Pelvis (male) – to include transabdominal prostate				Doppler – Lower Limb Arteries	L     R
   	
Abdomen & Pelvis (female) – to include TVS if indicated		Suspected hernia:
Groin & Inguinal Region

Anterior Abdominal Wall	L     R

	Doppler – Lower Limb Veins	L     R
   	
Pelvis (female) – to include TVS if indicated				Other investigation (please specify):      	
Urinary/Renal Tract/KUB
		Transrectal Prostate			
Testes
		Salivary glands			
Thyroid
		Parathyroids			

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

EMIS LV:  March 2016