Download imaging booking form - The Manchester Institute of Health

IMAGING REQUEST FORM
Referring Clinician:(please print)
X Number:
Appt. Date & Time:
Surname:
Address:
Forename:
Account to be billed
(tick)
PRIVATE GP PRACTICE
Address:
(No LOG required)
Telephone:
INSURANCE
(Pre-auth required for CT,
Postcode:
MRI and Nuclear Med.)
Patient Contact Details:
Date of birth:
CLIENT
E-mail / Fax:
(No LOG required)
Sex: Male
□
Female
Mobility: Walking
□
□
Chair
THIRD PARTY / EMBASSY
(LOG required)
□
Trolley
□
PATIENT
Preferred Radiologist:
(Payment required)
Authorisation No. / Fee Quoted:
Examination Requested:
Under the IR(ME)R 2000 regulations, all Imaging Requests must be justified by an Imaging Department practitioner to ensure that there is a
net benefit, from the examination, to the patient. Therefore, any request that is illegible, unsigned by a doctor or clinical nurse specialist or
lacking the required information will be returned for completion.
Clinical Information:
Referring Clinician Signature:
Date:
I V Contrast (Iodine or Gadolinium):
To minimise the risk of contrast nephrotoxicity it is the responsibility
of the referring clinician to provide an indication of renal status or to
ensure that a recent eGFR and a serum creatinine level are available.
Serum Creatinine:
eGFR:
Date measured:
Initials:
M R I:
Does the patient have any of the following contra-indications?
History of intra-orbital FB?
Intracranial Aneurysm clips?
Cardiac Pacemaker / ICD?
Prosthetic Heart Valve?
Exam Comments:
DAP:
Operator:
Date:
The Manchester Institute of Health and Performance
299 Alan Turning Way
Manchester M11 3BS
T: 0161 641 8300
HCA International Ltd | Registered Office: 242 Marylebone Road, London NW1 6JL. Registered in England No. 3020522
52AR.RAD.FORM.100
v2 Feb 15