Download imaging request - The London Clinic

IMAGING REQUEST
PATIENT INFORMATION
*TLC unit no.
(if known)
*indicates mandatory fields
Payment method
L
*Title
VASCULAR REQUEST
n Insurance
n Embassy
n Self-Pay
n Sponsor
Payment provider
*DOB
(dd/mm/yyyy)
Member no.
*Surname
Authorisation no.
*Forename(s)
Patient’s tel no.
*Gender
M
F
IP
OP
DC
BREAST IMAGING REQUEST
Patient’s email
Room
Patient’s address
*Referrer’s full name and / or practice stamp
Copy of reports to
PATHOLOGY REQUEST – TRANSFUSION
CLINICAL INFORMATION
Infectious
Yes
n No n
Oxygen required
n
Mode of transport:
If Yes:
Walking
Yes
n
No
Wheelchair
n
n
ONCOLOGY/HAEMATOLOGY
Yes n No n
Bed
Portable FORM
nBOOKING
n
Barrier nursed
Appointment
Date
N.B. This form is a legal document – Referrer’s Declaration
l
l
l
l
Time
l
X-Ray
US
CT
MRI
Nuclear Med
PET CT
Bone Density
Interventional
Breast Imaging
Examination requested
Clinical indication for examination. Please summarise relevant history,
clinical findings, previous imaging and test results. Indicate the question that the
examination should answer.
The correct patient details have been provided.
I have discussed the examination, including any intervention, with the
patient / guardian.
I have taken into account the possibility of pregnancy
I have given sufficient clinical information for the request to be justified
according to IR(ME)R 2000.
I will ensure that the examination results are recorded in the patient’s notes.
Imaging requiring intravascular contrast medium
(CT, Angiography, Venography, IVU, MR)
Serum creatinine / Estimated GFR:
Date measured:
Is patient taking Metformin?
Yes
No
Reaction to contract medium
Yes
No
Asthma
Yes
No
Allergy requiring medical treatment
Yes
No
Kidney disease/surgery
Yes
No
Dialysis
Yes
No
Does this patient have a cardiac pacemaker,
cochlear implant or intracranial aneurysm clips? Yes
No
Is there a history of:
For completion by the Imaging Department
Safety information (to be completed by the patient)
Do you think you may be pregnant? Yes
No
Maybe
LMP:
I declare that I am not pregnant
Patient’s signature:
Preferred Radiologist:
*Referrer’s Signature
Imaging Department
Tel : 020 7616 7653
Date:
Justified by Radiographer:
*Date
001147
www.thelondonclinic.co.uk
Imaging Department
7th and 8th Floor
20 Devonshire Place, London, WIG 6BW
Imaging Department
Lower Ground Floor
5 Devonshire Place, London, WIG 6HL
Tel : +44 (0)20 7616 7653
Tel: +44 (0) 20 7935 4444 extn 4902
X-Ray / US / Bone Densitometry / Neurophysiology / Vascular
Fax : 020 7616 7679
[email protected]
CT / MRI
Fax : 020 7616 7689
[email protected]
PET CT / Nuclear Medicine
Fax : 020 7535 5547
[email protected]
Breast Imaging
Fax : 020 7616 7690
[email protected]
Interventional
Fax : 020 7535 5528
[email protected]