InHealth Group - Making Healthcare Better



-73533021145500MRI REFERRAL FORM - Open Scanner for SWL CCGsPlease note – we are unable to accept referrals for breast MRI patients.Main reason for referral: Bariatric FORMCHECKBOX Claustrophobic FORMCHECKBOX Pain FORMCHECKBOX Bariatric criteriaPatient who cannot comfortably fit in closed MRI machines due to obesity will be accepted. Patient is over 21st (135kg) please indicate height and weight below? (open scanner table limit 47st)Height: Weight: BMI: FORMCHECKBOX Yes FORMCHECKBOX NoClaustrophobia criteria Patients who suffer from claustrophobia, where an oral prescription sedative* has not been effective in enabling the patient to undergo closed MRI will be acceptedHas the patient attempted a scan in a conventional scanner?Date of closed MRI attempted: Have other options been considered for Claustrophobic Patients?Feet first into scanner (L-spine, knees and feet)?Is the patient able to travel independently to an Open MRI Scanner?Are other diagnostic tests available? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoPain criteria Patients who cannot lie properly in a closed MRI machine due to severe pain or other significant medical conditions will be accepted. Please state reason why patient cannot lie properly in a closed MRI machine: FORMCHECKBOX Yes FORMCHECKBOX NoPlease include any information that will assist with the management of this patientPATIENTREFERRERNHS NumberNameForenameGMC/HPC/NMC NoSurnameAddressAddressDate of Birth (Over 16 only)Referring CCG CodeTelephone (Home)Referring Practice CodeTelephone (Work)Telephone No. (for urgent clinical findings)Telephone (Mobile)Fax No.E-mail mail onlyGenderMale FORMCHECKBOX Female FORMCHECKBOX EthnicityPhysical/Communication difficulties (specify if any): PRESENTING COMPLAINT & PROVISIONAL DIAGNOSISPlease provide as much relevant clinical information as possible to assist with the interpretation of the referral and images. Investigation(s) Required: please indicate which side of body and body part where appropriate.What is the patient’s presenting complaint?How long has the complaint been persisting?What treatment/management of the condition has been provided?What is the clinical question you require us to answer?Please tick box if this scan is related to recent (within 5 years) spinal or neurosurgery FORMCHECKBOX All referrers must complete the following MRI safety questions:Does the patient have any implanted metallic foreign devices? (e.g. cardiac pacemaker, artificial heart valve, cerebral aneurysm clips, cochlear implant etc.)Is the patient known to have metallic fragments in their eyes?Date of Referral Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Please post, fax or e-mail this form to the InHealth Patient Referral Centre:Sandbrook House, Sandbrook Way, Rochdale OL11 1RYTel: 0333 202 0297 Fax: 0333 200 1163 E-mail: inl.inhealthreferrals@Version: May 2018 ................
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