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	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 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: System Date	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

Version: April 2014

INHEALTH

Caroline

2014-04-14

Caroline.Meechan

InHealth Ltd