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Imaging Request Form

MRI, CT, X-Ray, Ultrasound

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Complete the Imaging Request Form

Patient Details

Name & Surname

Date of Birth

Street Address

City

State/Province

ZIP / Postal Code

Country

Tel. Number

Cell Number

Email Address

GenderMaleFemale

Start date of Menstrual Period

Patient ArrivalTrolleyWheelchairWalking

FundingSelf-FundedPrivate Patient

Patient's Insurance Company

Membership Number

Pre-authorisation NumberPlease Note: Uninsured patients & patients without pre-authorisation are required to pay on the day of their appointment.

Referral Information

Select ServiceMRICTX-RayUltrasound

Area to be imaged

Date of Test

Reason For Referral

Relevant previous medical history

Details(including any surgery & current medication)

Please attach copies of any recent X-rays or scan reports:

Drag and Drop (or) Choose Files

Safety Check

Could the patient be pregnant?YesNo

Is the patient breast feeding?YesNo

Is the patient a high infection risk?YesNo

If YES, please specify:

Is the patient diabetic?YesNo

Is the diabetes controlled by:N/ADietInsulinTablets

Is the patient on Metformin?YesNo

Does the patient have allergies?YesNo

If YES, please specify:

MRI Contraindications

Does the patient have:

A pacemaker?YesNo

A cerebral aneurysm clip?YesNo

Cochlear implants?YesNo

Neurostimulators?YesNo

Programmable hydrocephalus shunt?YesNo

Metallic foreign body in eye?YesNo

Other metallic implantsYesNo

Referring Clinician's Details

IR(ME)R 2000 regulations require this form to be signed by the referring Clinician

Consultant Name

Address

Tel. Number

Cell Number

Email Address

Today's Date

Please tick box *

I hereby accept and confirm that all information provided is correct and true.

Please tick box *

Yes, I agree with the privacy policy and terms and conditions.

Name & Surname

Date of Birth

Address

Tel. Number

Mobile Number

Email

Gender

Male Female

Start date of Menstrual Period

Patient Arrival:

Trolley Wheelchair Walking

Funding:

Self-Funded Private Patient

Patient's insurance company

Membership number

Pre-authorisation number

Select Service

MRI CT X-ray Ultrasound

Area to be imaged

Date of test

Reason for referral

Relevant Previous Medical History

Please attach copies of any recent X-rays or scan reports:

Could the patient be pregnant?

Yes No

Is the patient breast feeding?

Yes No

Is the patient a high infection risk?

Yes No

If YES, please specify:

Is the patient diabetic?

Yes No

Is the diabetes controlled by:

None Diet Insulin Tablet

Is the patient on Metformin?

Yes No

Does the patient have allergies?

Yes No

If YES, please specify:

Does the patient have:

A pacemaker?

Yes No

A cerebral aneurysm clip?

Yes No

Cochlear implants?

Yes No

Neurostimulators?

Yes No

Programmable hydrocephalus shunt?

Yes No

Metallic foreign body in eye?

Yes No

Other metallic implants

Yes No

IR(ME)R 2000 regulations require this form to be signed by the referring Clinician

Address

Tel. Number

Mobile Number

Email

Today's date

I hereby accept and confirm that all information provided is correct and true

Download our POPI Act Requirements here:

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Imaging Request Form

MRI, CT, X-Ray, Ultrasound

Complete the Imaging Request Form

Patient Details

Referral Information

Relevant previous medical history

Safety Check

MRI Contraindications

Does the patient have:

Referring Clinician's Details

IR(ME)R 2000 regulations require this form to be signed by the referring Clinician

All Rights Reserved © 2024

Hosted and Maintained by

Imaging Request Form

MRI, CT, X-Ray, Ultrasound

Complete the Imaging Request Form​

Patient Details

Referral Information

Relevant previous medical history

Safety Check

MRI Contraindications

Does the patient have:

Referring Clinician's Details

IR(ME)R 2000 regulations require this form to be signed by the referring Clinician

All Rights Reserved © 2024

Hosted and Maintained by

Complete the Imaging Request Form