Cobalt Appeal Fund

Request for Imaging
Web Booking Ref:0000

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Clinical Details

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Relevant Clinical Summary

Area to be examined

Imaging Modality

MRI : Ultrasound : X-ray :
(GMC reg. clinicians only) CT :

Urgency

Date Sent

...

Any Previous Imaging (if applicable)

Type

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Referrer Details

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e-mail

Address
for report

Referrer Name

Consultant
Speciality

Telephone

Postcode

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Patient Details

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Surname

Home
Address

First Names

Date of Birth

/ /

Sex
(at birth)

Patient weight

Postcode

Self-Pay / Insured

Home Tel

NHS Number

Work Tel

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Physicians Declaration

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Physician's Declaration for MRI Requests only:

Does the patient have a:

Cardiac Pacemaker
Intracranial Vessel Clips
Internal Hearing Device

YES - MRI examination IS NOT possible

NO

Might the patient have:

Metal Fragments in the eye
(e.g. from working on a lathe)

YES - An orbital x-ray scan may clear the patient for MRI examination

NO

Does the patient have:

Claustrophobia
1st Trimester Pregnancy

YES - Contact the MRI Unit or a Radiologist

NO

I confirm I have checked each of the above contraindications and answered to the best of my knowledge