Bexley CCG              X-RAY REFERRAL FORM
Please note – we are unable to accept referrals for patients under 16 years of age
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 ensure the most appropriate investigation is performed in accordance with the Ionising Radiation (Medical Exposure) Regulations 2000 and the 2007 Royal College of Radiologists’ Referral Guidelines.     If the clinical information you provide indicates that the X-ray requested is inappropriate we will contact you to suggest alternative imaging techniques.	
Date of Referral: ~[Today...]                       	    Referrer’s Signature ________________________________
                                                                          This form must be signed by the referrer to comply with IR(ME)R	
Investigation(s) Required: tick all required; please tick the boxes to indicate which side where appropriate
	
Abdomen		Hand	L    R 	Scapula	L    R 	
Ankle	L    R 	Heel	L    R 	Shoulder	L    R 	
Cervical Spine		Hip	L    R 	Skeletal Survey		
Chest		Humerus	L    R 	Thoracic Spine		
Clavicle	L    R 	Knee	L    R 	Tibia/Fibula	L    R 	
Elbow	L    R 	Lumbo-Sacral Spine		Wrist	L    R 	
Facial Bones		Mandible		Other (please specify body part and side):      	
Femur	L    R 	Orbits			
Foot	L    R 	Pelvis			
Forearm	L    R 	Scaphoid	L    R 		
For X-Ray examinations of females of child-bearing capacity, is there any possibility of the patient being pregnant?

Yes             No                                                            Date of last menstrual period       /       /      

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 Version: July 2016