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UME Group

Online Referral

Please complete the form below, or alternatively, download the referral PDF and send in the post.

Patient Details

Centre
Surname
Firstname
Date of birth
Gendermale     female
Address
Home Tel
Work Tel
Mobile Tel
Clinical Information
L. M. P.
Pregnancy Rule: In all women on reproductive capacity the clinician should consider the posibility of early pregancy. For most exminations the risk to the foetus is neglibagle during the first 28 days following commencement of the last period. However, examinations involving high dose to the pelvis (i.e. Abdominal or Pelvic CT, Barium Enema) should be confined to the first 10 days unless there are overriding clinical indications.
Please tick box and sign below to confirm that you are not pregnant
Signature:

Referring Clinicial Information

Name
Address
Tel
Fax

MRI Examination

Area to be scanned
Does the patient have:
A Cardiac Pacemaker no     yes
Cochlear Implant no     yes
1st Trimester Pregnancy no     yes
Any metallic implants no     yes
Metallic fragments in eyes no     yes
Other

X-ray / CT Examination

Please specify view(s) required
Area to be scanned
Does the patient have/take:
Renal impairment no     yes
Asthma no     yes
Insulin Dependent Diabetes no     yes
Metformin no     yes
Thyrotoxicosis no     yes
Allergies
Exposure to ionising radiation regulations: the practitioner requesting the X-ray / CT examination must be satisfied that it is necessary and that it will directly affect patient management. It must be ensured that the investigation has not already been carried out at this Centre or elsewhere. Any proposed variation from the current Royal College of Radiologist's guidelines must be discussed with a radiologist. Each request must be signed by a medical practitioner.

Ultrasound Examination

Area to be scanned
Biopsy required no     yes
Specify
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