X-Ray Request Form - Gloucestershire Hospitals NHS ...
|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 |
|Consultant | |GP | |
|Address for report | |Surgery address | |
| | |
|Copy to | |Ignore 28 day rule| |
| | |(√) | |
|Referrer’s name in capitals |
|For barium enema/CT colography, signing this form confirms patient’s fitness to take CitraFleet preparation. |
|For Radiology Department use |
|Signature: |Protocol: |
|Date: | |
|This form is to be shredded once scanned onto the Radiology system |GHNHSFT/Y0452/07.10 |
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