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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]