Procedure that requires prior approval prior to referral
Application form: - MRI Scanning – Open / Standing / Annual

Name of Referring Clinician
GP Name and Surgery
Patients NHS Number
Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf
Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service to enable full consideration of this funding request?
Is this a patient/guardian led application?
How urgent is this request?
Prior approval is required for all open and standing MRI scans. Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration.
Most Urgent: Decision needed within a week as the patient’s life may be in danger
Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate.
Routine: Decision needed in 4 to 6 weeks.
Clinical Criteria required for consideration of treatment / Please Tick
1.  Please indicate which type of scan is requested:
☐ Open
☐ Standing
☐ Annual scan
2.  Please provide details of the purpose of the scan and why it is appropriate?
3.  Is the application on the basis of the patient being claustrophobic?
a.  If so has the patient been reviewed by the Radiology Department and discussed their concerns regarding MRI scanning to alleviate any fears?
b.  Has the patient tried sedation and failed to tolerate the MRI scan?
c.  Has the patient tried sedation and failed to tolerate the MRI scan in a wide bore MRI scanner?
d.  Was sedation offered under clinical supervision (oral sedation)?
e.  Have other modalities e.g. CTP scan been considered as an alternative if suitable? / YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
4.  Has the Radiology Department formally assessed the patient and found them unsuitable (e.g. due to the size of the patient and the restriction of the MRI scanner)?
Please provide details of the patient’s Body Mass Index (BMI):
BMI / kg/m2
Height / cm
Weight / kg
Details of the habitus of the patient: / YES ☐ NO ☐
5.  Is the patient a non-smoker? / YES ☐ NO ☐

South, Central and West Commissioning Support Unit May 2017 TVPC53