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Microsoft word - referral 2008[2].doc

Easy Imaging Ltd
Plymouth Consultant Radiologists
Referral Form

PATIENT DETAILS

Surname: ……………………………First Name: ………………………… Date of Birth:…………………………….
Home Address: …………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….
Tel No (Daytime): …………………………………… Tel No (Evening): ……………………………………………….
PAYMENT DETAILS - (Please circle and give invoice details below if necessary)
Self Funding

Invoice to be addressed to: …………………………………………………………………………………………….….
……………………………………………………………………………………………………………….……………….
CLINICAL DETAILS

Suggested Examination: ………………………………………………………………….………………………………
Clinical Indications: ……………………………………………………………………………….………………………
…………………………………………………………………………………………………….………………………….
…………………………………………………………………………………………………….………………………….
Provisional Diagnosis: ………………………………………………………………….…………………………………
Please identify if the patient has any of the following:

Pacemaker: Yes / No
Electronically/magnetically operated implant devices: Yes / No On Warfarin
History of Intraoccular metallic Foreign Bodies: Yes / No Please specify:….……………………………………………………………………. Please specify:…………………………………………………………….………….

Referrer’s Signature: …………………………………………… Date: …………………………………………………
Name (please print): ………………………………………………………………………………………….……………
Address to which results are to be sent: …………………………………………………………………………………
……………………………………………………………………………………………………………………………….
A CD copy of the images for the patient and referrer is included in the cost of the examination
Additional Copy CD (extra charge) of images requested: Yes / No

Completed forms to be sent to Easy Imaging, Plymouth Consultant Radiologists, PO Box 231, Plymouth,

PL6 8WY, faxed to 01752 763257 or emailed to enquires@easyimaging.co.uk (Tel: 01752 432200)

Source: http://easyimaging.co.uk/Referral_2008_2.pdf

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