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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……..