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

EMIS PCS July 2015

Caroline Meechan

2015-07-23

InHealth Ltd