Site Map	Complete X-Ray Request Form / Nuclear Medicine Request Form

• Writing must be legible
• Fill in relevant patient details including (stickers acceptable)
  • Patient's name
  • Hospital ID
  • Date of birth
• Fill in details of requesting doctor / team
  • Consultant name
  • Location for results
• Identify:
  • Transport requirements
  • Interpreter requirements
  • Mobility status of patient
  • Oxygen requirements
  • Known allergies
  • Known asthmatic
  • Infection risk if present (eg MRSA)
  • Urgency of request
  • Date of patients next visit (if appropriate)
• Confirm patient is not pregnant (ionising radiation only)
  • Contact department if patient is pregnant
• Confirm patient not breast feeding if nuclear medicine study or contrast to be used
  • Contact department if patient is breast feeding
• Confirm patient does not have aneurysm clips or pacemaker (MRI only)
• Give brief relevent clinical history
• Identify clinical question to be answered by investigation
• Give dates and details of other relevant investigations
• Sign form indicating status
• Print name and bleep number

	Any comments or feedback please contact me by email: Tom Williams