Mri Request Form

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CAPPAGH NATIONAL
ORTHOPAEDIC HOSPITAL, FINGLAS,
DUBLIN 11.
The Sisters of Mercy
RF-RAD-05
ISSUE DATE: 29/07/2015
MRI Request Form
REVISION NO: 2
NEXT REVIEW: 07/2017
MRI DEPARTMENT: MRI REQUEST FORM
Phone: 01 8140361
Fax: 01 8140364
E-mail:
mri@cappagh.ie
PATIENT DETAILS:
Name:
Date of Birth:
Hospital Number:
Address:
Phone Number:
Referring Consultant:
OTHER HOSPITALS:
Source of Referral:
Inpt:
Outpt:
Purchase Order No.:
Mobility:
Walking
Wheelchair
Trolley
PATIENT SAFETY SCREENING:
Y/N
Y/N
Pacemaker/defibrillator
Diabetes/heart disease/kidney disease
Intra cranial aneurysm clips/neurostimulator
Recent surgery (in the past 6 weeks)
Artificial heart valve/cardiac stents
MRSA
Eye/ear implant
Claustrophobia
Ever had metallic fragments in eyes/skin
Pregnant/breastfeeding
Ever had allergic reaction to contrast agent
Serum Creatinine*:
MRI EXAMINATION REQUIRED:
CLINICAL INFORMATION/INDICATION:
*Serum Creatinine (within 6 weeks of scan date) is required if Gadolinium Contrast is indicated in the following patient
groups: ● patients 65yrs and above ● patients who have a history of renal disease ● patients who are in the perioperative liver
transplantation period. If you have any queries please ring the MRI Department.
Referrer’s Signature:
___________________________ Date:
___________________________
Bleep Number:
___________________________ Phone: ___________________________
Hospital/Department:
___________________________ Fax:
___________________________
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