Download North Derbyshire Medical Imaging Service

NORTH DERBYSHIRE MEDICAL IMAGING SERVICE
Magnetic Resonance Imaging (MRI) Request Form
Please complete in full otherwise we will be unable to accept your request
DATE OF BIRTH
WARD/DEPT
«Date_of_birth»
RECORD NO
CONSULTANT
SURNAME
«Surname»
FORENAME
«Forename»
ADDRESS
«Patient_address_house» «Patient_address_road»
«Patient_address_locality» «Patient_address_post_town»
POSTCODE
DATE/TYPE LAST X-RAY/SCAN
«Patient_post_code»
WALK
CHAIR
TROLLEY
NHS NO
«NHS_number»
BED
MOBILE
APPOINTMENT (for completion by imaging service)
The following section must be completed to check any contra-indications for MRI
MRI scanning of patients for whom MRI is contra-indicated could pose a serious risk so please complete this section
carefully
Before making a referral please indicate whether the patient has any of the
Please circle appropriate response:
following:
YES
NO
 Intra-cranial aneurismal clip/s
YES
NO
 Cardiac wire (eg pacemaker)
YES
NO
 Any body cavity metallic clips or wires for < 3 months
YES
NO
 Intra-orbital metallic foreign body (retained)
YES
NO
 Cochlear implant
YES
NO
 Neuro-stimulator
YES
NO
 Occular implant with retaining magnet
If you answered ‘yes’ to any of the above questions, MRI is contra-indicated
Please do not refer this patient for MRI as we will not be able to perform the scan
Before making a referral please answer the following questions:
Please circle appropriate response:
YES
NO
 Does the patient have abnormal renal function?
YES
NO
 Has the patient had or are they awaiting a liver transplant?
YES
NO
 Is there a possibility that the patient might be pregnant?
If you answered ‘yes’ to any of the above questions please call MRI on 01246 513674 before making this
request
For completion by Imaging Service
EXAMINATION REQUESTED (refer to guidelines ‘Making Best Use of a Department of
Clinical Radiology
DISCUSSED WITH:
QUESTIONS TO BE ANSWERED
RADIOGRAPHER:
CLINICAL INFORMATION (Examinations will not be performed unless sufficient clinical information is provided
REFERRER DETAILS:
NAME:
DESIGNATION:
CONTACT NO/BLEEP
Signature:
Date:
If you are a non-medical referrer please enter your individual NMR reference code here:
Oct 11
NMR……..