The Harley Street Clinic
Department of Radiology
Outpatient Diagnostic Centre
Telephone: 020 7935 7700 (Main Switchboard) Telephone: 020 7323 0365 (Nuclear Medicine and Ultrasound) Facsimile: 020 7323 0340 (Nuclear Medicine and Ultrasound) Telephone: 020 7487 3672 (Direct Line)Facsimile: 020 7486 2884Email: [email protected] RADIOLOGY REQUEST FORM
Please tick as appropriate X-ray U/S CT N/M MAMMOGRAPHY
Please send all relevant imaging with patient
Date of Birth: ././. Hospital Number: X.
Examination/s Requested - please see notes on reverse of this form
For Females between the ages 12-55 years
Is the Patient Pregnant? Yes
Clinical information - Please see notes on reverse of this form
For In-patients only:
Walking Wheelchair
For I.V. contrast examinations
Oxygen, Barrier Nursing, Disability, etc.
This form must be signed and dated by the referring clinician
Guidance Notes for Referrers
In accordance with the requirements of Ionising Radiation (Medical Exposures) Regulations 2000, the
referrer’s attention is drawn to the following protocols in use at The Harley Street Clinic.
A request for a radiological examination will be regarded as a request from one clinician or healthprofessional to the Imaging Department for an opinion, based upon a radiological examination, to assist in the management of a clinical problem.
Diagnostic imaging or radiological procedures will only be performed upon written request signed by a registered medical or dental practitioner or by an authorised non-medical practitioner.
Referrals (request form or letter) must precede or accompany the patient, Faxes are accepted.
All requests must carry sufficient information to identify the patient, normally consisting of first name, middle name if any, family name, date of birth and address.
All requests must carry sufficient clinical information to enable the requested examination to be justified. Referral criteria are based on the Royal College of Radiologist’s Guidelines - “Making thebest use of a Department of Clinical Radiology: Guidelines for Doctors”.
All requests shall clearly state the examination requested.
All requests must include contact details of the referring clinician including address and telephone number.
Females of Childbearing age (12 - 55 yrs)
All requests for X-rays, CT and Nuclear medicine examinations (between the diaphragm and the knee) of females of childbearing age (12-55yrs) must state the date of the first day of the patient’s last menstrual period.
Clinical Justifications of Requests
All requests for imaging will be assessed prior to exposure by the appropriate practitioner for the
examination to ensure that they meet with the Royal College of Radiologist’s Guidelines
and any local guidelines and that in their professional judgement they are clinically justified
(Royal College of Radiologist Publications: BFCR (00)5).
Examination Justified
& Authorised by

Females of Childbearing Age (12-55 yrs) - declaration to be completed by the patient and operator
Is there any possibility that you might be pregnant? Signed (patient):
/ / Signed (operator):
IV/Contrast Records
Contrast GivenReactionOther IV meds given Exposure Records
Film Usage


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