Candover Clinic Imaging Request Form

semper speravitPatient details Referrer Details

Surname:

First Name:

DOB:

Patient Address:

Post code:

Home Telephone Number :

Mobile Telephone Number:

Registered GP:

Referring GP / Consultant:

Send report to :

Tel Number(s):

Email:

Examination requested: Known Allergies:

Clinical Indications:

Referrer DeclarationThis is a legal document.The correct patients’ details have been given.I have discussed the examination with the patient/ guardian.I have provided sufficient clinical information for the request to be justified according to IR(ME)R 2000.I will ensure the results are recorded in the patients’ notes.

Referrer’s Signature: Date:

Print Name:

MRI disclaimerIf you have any of the following;

A cardiac (heart) pacemaker ● Aneurysm clips in your brain A cochlear implant ● A neuro stimulator Or any other medical devices

We may not be able to scan you. Please contact the MRI department before your appointment.

Candover Clinic Hampshire Hospitals NHS Foundation Trust

Telephone: 01256 315010/315011 - Facsimile: 01256 315033candoverclinic.com

Candover Clinic Imaging Request Form

semper speravitPLEASE RETURN THE SIGNED FORM BY FAX - 01256 315033

Candover Clinic Hampshire Hospitals NHS Foundation Trust

Telephone: 01256 315010/315011 - Facsimile: 01256 315033candoverclinic.com