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	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 requires 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.

Date of Referral: System Date
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 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

Version: April 2014

Caroline

2014-04-14

Caroline.Meechan

InHealth Ltd