Author: Caroline Meechan
Company: InHealth Ltd

Richmond CCG
ULTRASOUND REFERRAL FORM
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 fax or e-mail this form to the InHealth Patient Referral Centre:
Fax: 0333 200 1163                    E-mail: inl.inhealthreferrals@nhs.net
Tel: 0333 202 0297

www.inhealthgroup.com

Version: EMIS LV July 2015