PHOENIX HOSPITAL GROUP
+44 (0)20 7079 2100
Imaging Request

This form is for medical professionals only.
Please complete, and we will call you back shortly to confirm a date.

Patient Details

Examination/Procedure

Please select procedure(s):

 MRI CT X-Ray Ultrasound

MRI: Please complete the following safety questions

Does the patient have a Cardiac pacemaker, cochlear implants, cerebral aneurysm clips?*

Has the patient had surgery in the last 8 weeks?*

Does the patient have a history of metallic foreign body to the eye?*

Is there a possibility of pregnancy/breast feeding?*

Does the patient have or has had renal impairment? If so we need eGFR score before giving contrast.*

Provide eGFR score

Does the patient have a history of allergies?*

Does the patient have any implants or other foreign bodies in your body e.g. replacement joints, plates, drug pumps, wires, clips or shrapnel?*

CT: Please complete the following safety questions

Is there a possibility of pregnancy/breast feeding?*

Does the patient have or has had renal impairment?* If so we need eGFR score before giving contrast.

Provide eGFR score

Does the patient have a history of allergies?*

Any history of diabetes?*

Is the patient on metformin or glucophage?*

For all patients requiring I.V. Contrast

Has the patient had a contrast injection before? *

Is the patient likely to have a raised serum creatinine?*

X-Ray: Please complete the following safety questions

Is there a possibility of pregnancy? *

Ultrasound

There are no safety questions

For female patients

Referring Clinicians Details

How would you like to receive the report (please tick):

Email Post Fax 

Referrers Declaration

  • The correct details have been provided.
  • I have discussed the examination including any intervention.
  • I have taken into account possibility of pregnancy.
  • I have given sufficient clinical information for the requested to be justified according to IR (ME)R 2000.
  • There are no known contra-indications to performing the requested examination.
  • I will ensure the examination results are recorded in the patient notes.
  • The Ionising Radiation (Medical Exposure) Regulations 2000 require you to complete all this information accurately.
  • I confirm this is my approved signature