AQP DIRECT ACCESS RADIOLOGY REQUEST FORM

MRI

MRI exclusions: patients with known metallic fragments in their eyes or specified implanted medical devices (e.g. cardiac pacemaker, cerebral aneurysm clips, cochlear implant etc); pregnant women)

Please complete ALL fields below, incomplete forms may delay assessment.

All routine AQP MRIreferrals are to be generated via Choose and Book.

All other MRI requests should be referred to your local Trust

Any patient with suspected cancer should be referred through the 2WW referral pathway

Please do not scan reassurances.

***Use this form for routine requests only***

*Referrer Details: (reports should be sent to the referrer)
Referrer Name: / Registered GP:
Organisation (GP practice or ESP): / Practice Code:
Tel No: / Fax No:
NHS Email Address (generic practice): / Date Referred:
Professional registration code (GMC code):
*Patient Details:
UBRN: / NHS Number:
Surname: / Date of Birth: / Age:
Forenames: / Title:
Address (full):
Postcode: / Mobile No:
Home Tel No:
Ethnic Origin / Work Tel No:
*Please state area of body to be scanned
*Relevant Clinical Indications(key symptoms and signs. If possible please include details of any previous images or scans)
*Does patient meet criteria for AQP MRI Referral? (exclusions are listed overleaf for reference and information regarding pathways)
YES / NO
Has patient been seen by community physiotherapist prior to MRI request (for MSK referrals) / YES / NO
*Special Requirements (including mobility, claustrophobia, language support):
If an interpreter is required what language?

Exclusions for AQP Direct Access MRI

  • Contrast MRI

AQP Clinical exclusions

  • Cancer - any Patient with suspected cancer should be referred through the two week wait referral pathway;
  • Patients with a Body Mass Index exceeding the manufacturer’s health and safety guidance for weight limits of the MRI unit orcouch.
  • Patients withspecified implanted medical devices are MRI contraindicated(e.g. cardiac pacemaker, cerebral aneurysm clips, cochlear implant etc); and in certain cases implants are MRI conditionally safe. The referrer has a responsibility to provide information on all such devices, but the final responsibility for safety rests with the Provider in line with Provider protocols and relevant safety guidelines and resources.

Other AQP exclusions

  • Children under the age of 18
  • Patients requiring a general anaesthetic
  • Scans requiring the use of contrast
  • Hospital inpatients and
  • Non-NHS Patients.

Contraindications

  • a cardiac (heart) pacemaker
  • clips in the head from brain operations, ie aneurysm clips
  • a cochlear (ear) implant
  • a metallic foreign body in the patient’s eye
  • a programmable shunt for hydrocephalus (fluid on the brain)
  • If the patient is pregnant

Cautionary

  • Cerebral aneurysm clip in the brain
  • Heart valve Replacement
  • Intra-vascular stents, filters and coils
  • Ocular implants
  • Shrapnel injuries
  • Penile implants
  • Any other unknown implant until it has been determined as MRI safe
  • Patients with severe claustrophobia
  • Patients who have problems lying still or flat (such as patients with Parkinsons, some learning disabilities, colds (coughing or sneezing)

In some cases the patient may require an X-ray before an MRI scan, to make sure they are safe to enter the scanner.

*Mandatory field