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Radiology Request Form

This radiology request form provides instructions for referring clinicians to complete to request imaging examinations for their patients. It collects important patient details like name, DOB, NHS number as well as clinical information relevant to the specific examination. Referring clinicians must sign to authorize the request and priority of routine or urgent is indicated. Incomplete or illegible forms may be returned.

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Coco Choi
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9K views2 pages

Radiology Request Form

This radiology request form provides instructions for referring clinicians to complete to request imaging examinations for their patients. It collects important patient details like name, DOB, NHS number as well as clinical information relevant to the specific examination. Referring clinicians must sign to authorize the request and priority of routine or urgent is indicated. Incomplete or illegible forms may be returned.

Uploaded by

Coco Choi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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GP Radiology Request Form

INCOMPLETE / ILLEGIBLE FORMS WILL BE RETURNED in line with IRMER 2000 regulations
Please ensure ALL fields are completed

PATIENT DETAILS:
Name:       NHS Number:      
Date of Birth:       Gender: Male Female
Address:       Tel Number:      
      *Mobile Number:      
Postcode:       Email:
Interpreter Required: Yes No
If interpreter required which language:      
Ethnic Origin:      
Pregnancy status: Not Pregnant Pregnant
LMP:       If yes: Gestation weeks:     
*please note patients may receive text messages regarding their appointment

SERVICE SPECIFIC REFERRAL INFORMATION:

Priority: Routine: Urgent:

Examination Requested including body area to be imaged:      

X-ray Ultrasound MRI

CT For CT please state eGFR:       Diabetic status:       Allergies:      

Relevant Clinical Information: (as examination is protocol based, the quality of this information is important:

Question to be answered:

REFERRING CLINICAN:
Referrer Name:       Date of Referral:      
GMC number: Tel Number:      
Referring Practice:      
Practice Address:      
     
Postcode     :

Authorised by signature of referring clinician):


FOR YOUR INFORMATION

Radiology Department Radiology Department Evelina London Children’s Hospital


St Thomas Hospital Guys Hospital St Thomas’ Hospital
1st Floor Lambeth Wing 2nd Floor Tower Wing Children’s Imaging, Arctic Floor
Westminster Bridge Road, SE1 Great Maze Pond SE1 9RT Lambeth Palace Road, London, SE1 7EH
7EH
Tel No. 020 7188 5490 Tel No. 020 7188 5527 Tel No. 020 7188 9218
Appointments 020-718-85542 Appointments 020-718-85542 Appointment 0207 7188 9218

Email: [email protected]

The following tests require an appointment:- IVU, Ultrasound, Barium /Swallow/Meal/Enema./MRI/CT

Please make sure your Full Address and Telephone Number is clearly printed on the form.

All other general x rays are performed on a ‘walk in’ basis at either:
-Guys hospital in the main X-ray Dept located on the 2nd Floor Tower Wing. Opening hours are from 8.30am-5pm Monday to Friday
Or at
-St Thomas Hospital, the main X-ray Dept, located on the 1st floor Lambeth Wing. Opening hours are from 8:30am-5pm Monday to Friday
Or at
-Evelina Children’s Hospital, the main X-ray Dept located on the Children’s Imaging, Arctic Floor. Opening hours are from 9:00am -5 pm
Monday to Friday. Full address and telephone numbers detailed above

If you need an interpreter please advise your GP

The results of your examination will be sent to your GP and should be available in 7 -10 days after your scan. Please make arrangements with
your GP practice to be informed about your results.

To help us decide if you are entitled to free NHS care, you are requested to bring proof of identity and a proof of address with you.
If you are not entitled to free NHS care, you will be asked to pay for your treatment.

CAR PARKING FACILTIES ARE VERY RESTRICTED PLEASE USE PUBLIC TRANSPORT WHEREVER POSSIBLE.
Guy’s Hospital is situated near London Bridge Station
St Thomas Hospital is situated near Waterloo Station and Westminster Bridge.
(2) Form 1056

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