Chelsea and Westminster Hospital
NHS Foundation Trust

GP RADIOLOGY REQUEST

Patient Details	General Practitioner Details	
Forename	«PATIENT_Forename1»	Referring GP	«PATIENT_Registered_GP»	
Surname	«PATIENT_Surname»	Practice Address

	«PRACTICE_BlockAddress»	
Address	«PATIENT_BlockAddress»			
DoB	«PATIENT_Date_of_Birth»			
Gender	«PATIENT_Sex»			
Telephone	«PATIENT_Main_Comm_No »	Telephone	«PRACTICE_Main_Comm_No»	
Interpreter required?
(valid only for booked appointments)	Yes 	No 

Language      	Fax	     	
		
Referral Date	«SYSTEM_Date»	
NHS number	«PATIENT_Current_NHS_Number»	Request valid for 2 months from referral date	
C&W Hospital Number (if known)	     	Priority	Routine        Urgent 	
Referral Information	
Type of examination requested (please select from drop down)		
Area to be imaged – please be as specific as possible	     	
Clinical Information: Examination cannot be performed without sufficient clinical information (Ionising Radiation Medical Exposure Regulations 2000)
     	
Start date of Last Menstrual Period (if applicable):	     	
CT, MRI angiography and interventional procedures are only available through the appropriate specialty, rather than a direct access service (unless suggested by previous radiology report)	
Please tick if South Westminster Centre is preferred site (not possible for all diagnostics)			
Has the patient had a radiological examination at Chelsea and Westminster Hospital or the South Westminster Centre before?	Yes   	No   
Please specify 	     	
If URGENT treatment is necessary following the examination, are you happy for the patient to be referred to a C&W clinician?	Yes   	No   	
GP Signature: 	Radiographer/Radiologist justification Signature:

ILLEGIBLE OR INCORRECTLY COMPLETED FORMS WILL BE RETURNED AND RESULT IN DELAYS TO THE SERVICE	
Chelsea & Westminster Hospital Radiology Department
1st Floor, Lift Bank D
369 Fulham Road
London SW10 9NH
Tel: 020 8746 8570	X-ray: Patients should attend with this request form Mon – Fri, 8am – 7.45pm. Typically the quietest time is 6-7pm.

Ultrasound: Please fax this form to 020 8746 8588 and the patient will be posted an appointment. Alternatively, if the patient wishes to discuss their appointment date they should wait at least 24 hours from referral before calling.