MRI Imaging request form

Request form for MRI Scan
Examination required
One body are only
IMPORTANT: Please contact 624098 if patient has any of the following:
- A PACEMAKER
- ANEURYSM CLIP/BRAIN SURGERY
- BIO OR NEURO STIMULATOR
- COCHLEAR IMPLANT
- HISTORY OF METAL IN THE EYES
Clinician referral type
Patient details
Title
Mr, Mrs, Mstr, Miss, Ms.
URN:
Unit record number (Issued by the hospital)
Name

SurnameFornames
Current Address

Street Address

Street Address Line 2

ParishState / Province

Post Code
Date of birth
Telephone contact
Please enter a valid phone number
Telephone work
Please enter a valid phone number
Is the patient private?
Payment method if private?
Clinical history
FEMALE PATIENTS AGED 12 - 55 SEE BOTTOM HALF OF FORM
What specific information do you require from this study?
Relevant clinical information (including previous imaging)
Consultant / G.P name
Doctor's signature
Date

DayMonthYear
Date
G.P. No.
RADIO FREQUENCY RADIATION OF FEMALES OF CHILD BEARING AGE
If the uterus could be exposed to radiation in a female of child bearing age, compliance with the following protocol is required:

REFERRING CLINICIAN:

If for any reason pregnancy status is to be ignored, you must ensure that the patient is aware of the potential risks to the embryo/foetus and that she consents to the examination.

If the patient is unconscious/incapable, clinical needs may override the potential risks to the embryo/foetus.

Sign below to authorise the irradiation of a pregnant patient, or a patient where the pregnancy status is unknown.
Name

First NameLast Name
Email
example@example.com
Telephone contact
Clinician's signature
Bleep No.
Date

DayMonthYear
Date
RADIOGRAPHER OR RADIOLOGIST:

The following must be completed at the time of the examination, unless overruled by the referring clinician.

Explain to the patient that radiation may be harmful to the unborn child. Ascertain the date of their last period.
Date of the first day of the last period (LMP)
PLEASE NOTE:

FALSE POSITIVE AND FALSE NEGATIVE RESULTS CAN BE OBTAINED FROM PREGNANCY TESTS CARRIED OUT BEFORE THE FIRST DAY OF A MISSED PERIOD.
Should be Empty:

Request form for MRI Scan

Patient details

FEMALE PATIENTS AGED 12 - 55 SEE BOTTOM HALF OF FORM

RADIO FREQUENCY RADIATION OF FEMALES OF CHILD BEARING AGE