Email completed form to
foscote.radiology@nhs.net or radiology@thefoscotehospital.co.uk
Imaging Request Form
Patient Surname: Referring Clinician: Hospital Number:
Patient Given Name: DOB:
Patient Address: Patient Contact Details:
Sex: Is this case urgent?
Postcode:
Y N
Referrer’s declaration (NB: This form is a legal document)
I have discussed the examination with the patient/guardian. Examinations can NOT be performed without sufficient clinical
information and a doctor’s signature in line with Ionising Radiation (Medical Exposure) Regulations 2000.Correct patient details
have been given (Areas in BOLD must be completed).
Examination(s) requested (*If for MRI or for Injection please complete below):
Relevant Clinical Information and Clinical Question
Referrers Signature: Date:
*Warning MRI:
Does the patient have a cardiac pacemaker? Y N Has the patient had any brain surgery? Y N
Does the patient have artificial heart valve? Y N Has the patient got any metal in their body? Y N
Has the patient ever had metal fragments in their Y N
eyes?
*Patients undergoing injections:
Warfarin/blood thinning medicines? Y N Epilepsy/backouts/fits? Y N
Allergies? Y N Driving home? Y N
Asthmatic Y N Steroid injection in the last 3 months? Y N
Heart disease/high blood pressure? Y N
FOR OFFICE USE ONLY
Received Sent for Vetting Vetted Contacted Appointment Imaging Sent for Reported by Report sent to
by Patient booked performed by reporting referrer
Vetting outcome: Patient prep:
Date:
Radiographer/Operator: Date of examination:
Operator Use: Dose (cGycm2):
kVp: mAs:
Screening time: Number of Exposures Accepted: Rejected:
RAD-DOC05 Imaging request form V4 Issue date26/02/2020 Review date :Feb 2023
The New Foscote Hospital, 2 Foscote Rise, Banbury, Oxfordshire OX16 9XP Tel 01295 252281
MRI Safety Screening Form
The following questionnaire is designed to identify metallic items in the body that may cause harm if taken into the MRI
scanner magnetic field. Please read the Patient Information Leaflet ‘MRI Examination’ which explains the examination
and safety precautions required. You must complete this questionnaire before your appointment and contact the
Radiology department if you answer ‘YES’ to any of the questions from 1 to 5, so there is no delay or postponement to
your scan.
QUESTIONS – please tick yes or no in the columns provided YES NO
Have you ever been fitted with a cardiac (heart) pacemaker or implant defibrillator (ICD)?
If YES, please describe. You must tell staff IMMEDIATLEY
Have you ever undergone any surgery or other procedures to your heart?
If YES, please describe, including any dates and where this was carried out
Have you ever had any of the following medical implants:
Aneurysm clip
Programmable hydrocephalus shunt
Cochlear implant
Neurostimulator
Implantable drug infusion pump
Have you EVER had any metal fragments in your eyes?
If you answered YES – did you seek medical and did a doctor tell you everything had been completely
removed?
If YES, you may need an x-ray, speak to staff IMMEDIATLEY.
Have you had any other surgery to your head or spine? (including eyes and ears)
If YES, please describe:
Have you ever suffered from epilepsy or have you ever had a fit/blackout?
Have you ever had any shrapnel (fragment of metal) injuries to your body?
Have you had any operations that involved metal clips, pins, plates or other implants? (including any
joint replacements) If YES, please describe:
Have you had any operations or other medical procedures in the last 6 months?
Do you wear a medicine patch? (Fentanyl, nicotine, HRT etc)
Do you have any tattoos, permanent cosmetics or piercings?
Female patients only: Is there a possibility of you being pregnant?
If you have answered YES to any questions from 1-5, please contact the MRI department immediately.
Forename…………………………………………………………. To be completed at appointment only:
Surname…………………………………………………………… The MRI scan procedure has been explained to me by
the radiographer; I have removed all metal objects
Date of birth…………………………………………………….. (mobile phone, jewellery, hearing aids, metal dentures,
prosthetic limb etc) and have answered the questions
Address……………………………………………………………. above to the best of my knowledge.
………………………………………………………………………… Patient signature………………………………………
………………………………………………………………………… Date: ………………………………………………………
Weight………………….KG Height………………………. Radiographer signature…………………………….
Date: ………………………………………………………
RAD-DOC31 MRI safety screening form V1 Issue date 18/02/2020 Review date: Feb 2023
