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University Hospitals Birmingham NHS Foundation Rusticating REFERRAL FORM
PATIENT DETAILSREFERRER DETAILSName:GP name:Date of birth:GMC no:Address and
postcode:NMR name and EPP
number
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How to fill out routine imaging referral form
How to fill out routine imaging referral form
01
Obtain the routine imaging referral form from the imaging facility or download it from their website.
02
Fill out the patient's personal information such as name, date of birth, and contact information.
03
Specify the type of imaging test requested and provide relevant medical history information.
04
Include the referring physician's information and signature to complete the form.
05
Submit the filled out form to the imaging facility either in person, by fax, or through their online portal.
Who needs routine imaging referral form?
01
Patients who have been recommended by their healthcare provider to undergo routine imaging tests.
02
Healthcare providers who want to refer their patients for routine imaging screenings or diagnostic tests.
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What is routine imaging referral form?
A routine imaging referral form is a document used by healthcare providers to request imaging studies, such as X-rays, MRIs, or CT scans, for patients.
Who is required to file routine imaging referral form?
Healthcare professionals, such as physicians or specialists, who are requesting imaging services for their patients are required to file a routine imaging referral form.
How to fill out routine imaging referral form?
To fill out a routine imaging referral form, a healthcare provider should complete the patient's information, select the appropriate imaging study required, provide clinical details, and sign the form.
What is the purpose of routine imaging referral form?
The purpose of the routine imaging referral form is to ensure that imaging studies are medically necessary, properly documented, and align with appropriate clinical guidelines.
What information must be reported on routine imaging referral form?
The information that must be reported includes patient demographics, clinical indication for the imaging, specific type of imaging requested, and the healthcare provider's contact details.
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