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Imaging Request Form

The radiology request form collects essential patient information such as name, date of birth, contact details, medical history, and type of imaging exam requested. It also requires information on the referring clinician and their signature. The form is used to schedule and prioritize imaging exams and ensure patient safety for procedures requiring contrast or bowel preparation.

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elmore kaka
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1K views1 page

Imaging Request Form

The radiology request form collects essential patient information such as name, date of birth, contact details, medical history, and type of imaging exam requested. It also requires information on the referring clinician and their signature. The form is used to schedule and prioritize imaging exams and ensure patient safety for procedures requiring contrast or bowel preparation.

Uploaded by

elmore kaka
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
  • Radiology Request Form: This page contains a Radiology Request Form for the Oasis Medical Centre, including sections for patient details, referring doctor's information, and required scans.

Radiology Request Form

Please complete all relevant sections and send to the appropriate Radiology department
Modality: X-Ray Ultrasound CT MRI Other (Please specify)
(Please circle)
Body part:
Patient Details (A signed addressograph label may be affixed here) ↓
History: Surname:
Clinical findings, previous operations, questions to be answered

First Name:

Address:

Postcode:
Date of Birth DD/MM/YYYY

Sex M F

Ward: (if in-patient) Patient Tel:

Infection risk? NHS No.


If yes, give details
Recent creatinine MRN No
(if IV contrast required)

Priority & Status (please circle) In turn Urgent IP OP NHS PP


Referrer Details
Consultant GP

Address for report Surgery address

Ignore 28 day
Copy to Reason
rule
Referrer’s signature (√)
Date of
(if this does not appear on
addressograph label request
above)
Medical/
Referrer’s name in capitals Bleep No.
non-medical
For MRIs, signing this form implies confirmation that none of the following contra-indications apply:
Cardiac pacemaker; metal in orbit; internal hearing device; intracranial vessel clip; valve replacement;
metallic foreign body; claustrophobia
For barium enema/CT colography, signing this form confirms patient’s fitness to take CitraFleet
preparation.
For Radiology Department use
Signature: Protocol:

Date:

Radiology Request Form Please complete all relevant sections and send to the appropriate Radiology department Modality: (Plea

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