Barking and Dagenham, Havering and Redbridge CCGs

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 Dec 2014

INHEALTH

Caroline

2014-12-08

InHealth Ltd