Waltham Forest CCG, Newham CCG and Tower Hamlets 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	Registered GP
Forename	Forenames	GMC/HPC/NMC No
Surname	Surname	Address	Practice Address Stacked
Address	Patient Address Stacked
Date of Birth	DOB	Referring PCT Code
Telephone (Home)	Home Telephone	Referring Practice Code
Telephone (Work)	Work Telephone	Telephone No.

(for urgent clinical findings)	Practice Main Telephone
Telephone (Mobile)	Mobile Telephone	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: Ethnic Origin
PRESENTING COMPLAINT & PROVISIONAL DIAGNOSIS

Please provide as much relevant clinical information as possible to assist with the interpretation of the referral and images.

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

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 System Date

Yes No

Yes No

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 PCS Feb 2016

INHEALTH

Caroline Meechan

2016-02-01

InHealth Ltd