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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]