Diagnostic referral form – Guys and St Thomas Specialist Care

Requested procedure(Required)

Location(Required)

Please provide details(Required)

PET-CT(Required)

Chemotherapy

Radiotherapy

Recent biopsy

None of the above

MRI(Required)

Metallic fragments in body

Cardiac pacemaker/ICD

Cochlear implant

Intracranial aneurysm clips

Other metallic implants

None of the above

CT/MRI(Required)

Reaction to contrast media

Kidney disease/surgery

Dialysis

None of the above

Last session(Required)

Next session(Required)

Please provide details(Required)

Patient name(Required)

Prefix First Last

Hospital number

Address(Required)

Street Address City ZIP / Postal Code Country

Gender(Required)

Male

Female

Non-binary

Prefer not to say

Weight

Date of birth(Required)

Email(Required)

Telephone(Required)

Interpreter required

Yes

No

Language

Payment details

Payment provider

Please provide details

Clinical indication for examination(Required)

Please summarise relevant history, clinical findings, and previous test results. Please indicate the question that the examination aims to answer.

Previous imaging/ reports file

Max. file size: 70 MB.

Name(Required)

First Last

GMC(Required)

Address(Required)

Street Address City ZIP / Postal Code Country

Telephone

Email(Required)

Signature(Required)