Download Referral form - Guy`s and St Thomas` NHS Foundation Trust

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Cardiac MRI Referral form
Referrals for cardiac MRI can only be made by a medical doctor.
PATIENT INFORMATION
Patient First name:
Patient Surname:
DOB:
Hospital number:
Address:
NHS number:
Home number:
Mobile number:
GP
GP name:
GP address:
REFERRAL INFOMATION
Patient status
IP
OP
PP
Referral
Urgent
Routine
Planned
Examination requested:
Clinical information:
HISTORY OF THE PATIENT:
Renal status:
History of renal disease
eFGR mL/min:
Date:
Infection status of patient:
Sinus
Atrial fibrillation
Additional information for stress
studies
Asthma
No known ECG abnormalities
History of Bradycardiac or AV Blocks
Severe COPD
Regular use of inhalers
MR CONTRAINDICATIONS (to be completed before referral to ensure patient safety)
Cardiac Pacemaker
Surgery in last 6-8 weeks
Surgery to heart
Had surgery to:
Brain
Spine
Eyes
Ears
Cerebral aneurysm clip
Pregnant
Implanted device
History of metal in eyes
REFERRING CLINICIAN
Name:
Speciality
Department:
Hospital
Tel:
Fax:
Signature:
Date:
This referral is for the CARDIAC MRI SERVICE at GUYS AND ST THOMAS’ HOSPITAL, please complete and
forward to the cardiac MRI office. Fax: 020 7188 5442 Email: [email protected]
Internal use only:
Vetting:
Contrast required:
Yes
No (please specify which contrast)
Vetting consultant signature:
Date:
Appointment date:
Appointment time:
Clinical Cardiac MRI Service, Department of Cardiovascular Imaging, Division of Imaging Sciences & Biomedical Engineering, 4th Floor Lambeth
Wing, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH
Tel: 020 7188 5441 / Fax: 020 7188 5442/ Email: [email protected]