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
Gender	male 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
Please check this form carefully before pressing the submit button.
Medtel International, 64 Harley Street, London, W1G 7HB, tel 0800 028 2288, fax 0207 636 4227 email bookings@medtel.co.uk

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Online Referral

Patient Details

Referring Clinicial Information

MRI Examination

X-ray / CT Examination

Ultrasound Examination