Diagnostic Ultrasound Referral Request Form Logo
  • Ultrasound Referral Request Form

  • Patient Information :

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  • Information for healthcare professionals: 

    This Imaging Request Form must include as much relevant patient clinical history and information as possible, plus additional information of those referring the patient - including contact details and specific requests for areas to be included in the full report.

    We request that referrals are limited to the assessment of one, or more, of the following (or suspected) conditions:

    Shoulder

    • Evaluation of injury to tendon, muscle or muscle/tendon junction

    • Rotator cuff/biceps tendinopathy, (subscapular, supraspinatus, infraspinatus will all be individually evaluated)

    • Biceps subluxation

    • Bursitis

    • Impingement - calcification

    • Acromioclavicular joint pathology

    Knee

    • Abnormality of tendons or bursae about the knee; or

    • Meniscal cyst, popliteal fossa cyst, mass or pseudomass; or

    • Injury of collateral ligaments

    Hand/wrist

    • Tendon disease or synovitis,scapho-lunate instability. Median nerve pathology may be indicated

    Elbow

    • Tennis or golfer’s elbow, synovitis, bursitis or ulnar nerve pathology

    Ankle/foot

    • Suspected tendinosis or synovitis, plantar fascitis, fibromatosis, Morton’s neuroma, foreign body

    We will contact the patient as soon as we receive the referral form and if the imaging request is appropriate for the investigation we will arrange an appointment. Payment will be taken at the time of booking. If the request is unclear or not suitable for ultrasound we will contact the referrer to discuss. 

    Following the ultrasound investigation, a comprehensive, clinical report will be produced and shared with the referrer within two working days to the email address given. 

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