Mri Request Form printable pdf download

Mri Request Form

CAPPAGH NATIONAL

ORTHOPAEDIC HOSPITAL, FINGLAS,

DUBLIN 11.

The Sisters of Mercy

RF-RAD-05

ISSUE DATE: 29/07/2015

MRI Request Form

REVISION NO: 2

NEXT REVIEW: 07/2017

MRI DEPARTMENT: MRI REQUEST FORM

Phone: 01 8140361

Fax: 01 8140364

E-mail:

mri@cappagh.ie

PATIENT DETAILS:

Name:

Date of Birth:

Hospital Number:

Address:

Phone Number:

Referring Consultant:

OTHER HOSPITALS:

Source of Referral:

Inpt:

Outpt:

Purchase Order No.:

Mobility:

Walking

Wheelchair

Trolley

PATIENT SAFETY SCREENING:

Y/N

Pacemaker/defibrillator

Diabetes/heart disease/kidney disease

Intra cranial aneurysm clips/neurostimulator

Recent surgery (in the past 6 weeks)

Artificial heart valve/cardiac stents

MRSA

Eye/ear implant

Claustrophobia

Ever had metallic fragments in eyes/skin

Pregnant/breastfeeding

Ever had allergic reaction to contrast agent

Serum Creatinine*:

MRI EXAMINATION REQUIRED:

CLINICAL INFORMATION/INDICATION:

*Serum Creatinine (within 6 weeks of scan date) is required if Gadolinium Contrast is indicated in the following patient

groups: ● patients 65yrs and above ● patients who have a history of renal disease ● patients who are in the perioperative liver

transplantation period. If you have any queries please ring the MRI Department.

Referrer’s Signature:

___________________________ Date:

___________________________

Bleep Number:

___________________________ Phone: ___________________________

Hospital/Department:

___________________________ Fax:

___________________________

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Mri Request Form

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