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UME Health

Imaging Referral Form

Telephone: 0207 467 6190
17 Harley Street, London W1G 9QH
Patient details (affix label if available)
Title: [esigninja formid="7" field_id="81" display="value" ] Address: [esigninja formid="7" field_id="88" display="value" ]
Firstname: [esigninja formid="7" field_id="82" display="value" ] Surname: [esigninja formid="7" field_id="83" display="value" ]
Dob: [esigninja formid="7" field_id="84" display="value" ] Gender: [esigninja formid="7" field_id="85" display="value" ]
Postcode: [esigninja formid="7" field_id="89" display="value" ] Phone number: [esigninja formid="7" field_id="86" display="value" ]
Funding type: [esigninja formid="7" field_id="90" display="value" ] Insurance company: [esigninja formid="7" field_id="91" display="value" ]
Email Address: [esigninja formid="7" field_id="112" display="value" ] Policy number: [esigninja formid="7" field_id="92" display="value" ]
Mobility: [esigninja formid="7" field_id="87" display="value" ] Authorisation code: [esigninja formid="7" field_id="93" display="value" ]
Examination/Procedure: [esigninja formid="7" field_id="94" display="value" ]  
Body part: [esigninja formid="7" field_id="95" display="value" ] Clinical indication: [esigninja formid="7" field_id="96" display="value" ]
Diagnostic Tests
Diagnostic Tests: [esigninja formid="7" field_id="97" display="value" ]  
Contrast investigations
For patients above 65 years of age or with any known problems with kidney function, serum creatinine level or eGFR must be available prior to imaging.
Serum creatinine/eGFR reading: [esigninja formid="7" field_id="98" display="value" ] Date Taken: [esigninja formid="7" field_id="120" display="value" ]

Safety check as recommended by the MHRA, the referring clinician is required to assess patient safety for MRI scans.
Cardiac pacemakers, artificial heart valves, cochlear implants, cerebral aneurysm clips are contra-indicated for MRI.
Does the patient have a metal implant or pacemaker? [esigninja formid="7" field_id="100" display="value" ]
Has the patient ever had an injury to the eye involving a metallic object? [esigninja formid="7" field_id="101" display="value" ]
Referring clinician’s details
Referrer name: [esigninja formid="7" field_id="102" display="value" ] Date: [esigninja formid="7" field_id="104" display="value" ]
GMC number: [esigninja formid="7" field_id="105" display="value" ] Contact Telephone Number: [esigninja formid="7" field_id="106" display="value" ]
Email Address: [esigninja formid="7" field_id="121" display="value" ] Preferred Radiologist: [esigninja formid="7" field_id="148" display="value" ]
Please indicate how you would like to receive
the results of the investigation?:
[esigninja formid="7" field_id="108" display="value" ]
Encrypted Email: [esigninja formid="7" field_id="122" display="value" ] Postal Address: [esigninja formid="7" field_id="123" display="value" ]
Do you wish to receive a CD copy of images?: [esigninja formid="7" field_id="109" display="value" ]  

Leave this empty:

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Signature Certificate
Document name: Imaging Referral Form
lock iconUnique Document ID: 7355f26a7fbf79e0eea500008d2e286102c4e61e
Timestamp Audit
September 13, 2021 9:35 am GMTImaging Referral Form Uploaded by Shimaa Ahmed - IP