REFERRER DETAILS PATIENT DETAILS

[Pages:1]DIAGNOSTIC IMAGING EXAMINATION REQUEST

(All fields must be completed)

Please fax completed form to 01 8368456

REFERRER DETAILS

Name: Address:

Glasnevin, Dublin 9

Modern Healthcare,Traditional Values

PATIENT DETAILS

Name: Address:

Tel:

Fax:

Email:

Tel: DOB: Sex: Private Health Insurance

Mobile:

Male Yes

O Female O O No O

EXAMINATION REQUIRED (Please tick required examination(s))

Exam Type

ABI

O

CT (please indicate if IV contrast is required)

O

Dexa

O

Doppler Ultrasound (please specify)

O

Fluroscopic Examination (please specify)

O

MRI (please indicate if IV contrast is required)

O

Ultrasound

O

X-Ray (please specify)

O

Region to be imaged

ADDITIONAL INFORMATION

Is there any chance that the patient is pregnant?

Yes O

No O

Date of when last Menstruation started (Applicable to females aged 11 ? 55 years)

Does the patient have any known Allergies; suffer from Asthma, Diabetes or Renal Disease / Impairment? Yes O

If yes, please give details

No O

CLINICAL INFORMATION

Ref: 131106 Date: 15/3/13

GP Signature:

Bon Secours Hospital Glasnevin, Dublin 7 Tel: 01 8065300 bonsecours.ie

Date:

DIAGNOSTIC IMAGING DEPT:

Appointments: Enquiries: Opening Hours:

Tel: 01 8065316 Tel: 01 8065497 Monday - Friday

Fax: 01 8368456 7.45am - 4.45pm

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download