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Microsoft word - referral 2008[2].doc

Easy Imaging Ltd
Plymouth Consultant Radiologists
Referral Form

PATIENT DETAILS

Surname: ……………………………First Name: ………………………… Date of Birth:…………………………….
Home Address: …………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….
Tel No (Daytime): …………………………………… Tel No (Evening): ……………………………………………….
PAYMENT DETAILS - (Please circle and give invoice details below if necessary)
Self Funding

Invoice to be addressed to: …………………………………………………………………………………………….….
……………………………………………………………………………………………………………….……………….
CLINICAL DETAILS

Suggested Examination: ………………………………………………………………….………………………………
Clinical Indications: ……………………………………………………………………………….………………………
…………………………………………………………………………………………………….………………………….
…………………………………………………………………………………………………….………………………….
Provisional Diagnosis: ………………………………………………………………….…………………………………
Please identify if the patient has any of the following:

Pacemaker: Yes / No
Electronically/magnetically operated implant devices: Yes / No On Warfarin
History of Intraoccular metallic Foreign Bodies: Yes / No Please specify:….……………………………………………………………………. Please specify:…………………………………………………………….………….

Referrer’s Signature: …………………………………………… Date: …………………………………………………
Name (please print): ………………………………………………………………………………………….……………
Address to which results are to be sent: …………………………………………………………………………………
……………………………………………………………………………………………………………………………….
A CD copy of the images for the patient and referrer is included in the cost of the examination
Additional Copy CD (extra charge) of images requested: Yes / No

Completed forms to be sent to Easy Imaging, Plymouth Consultant Radiologists, PO Box 231, Plymouth,

PL6 8WY, faxed to 01752 763257 or emailed to enquires@easyimaging.co.uk (Tel: 01752 432200)

Source: http://easyimaging.co.uk/Referral_2008_2.pdf

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Microsoft word - travel vaccination form_new version.doc

ROYSTON HEALTH CENTRE TRAVEL VACCINATION FORM Ideally we require two months notice to enable us to deal with your request Personal details Dates of trip Itinerary and purpose of visit (please attach any additional countries on a separate sheet) How far away is medical help if none available at destination? Please tick below, as appropriate, to best describe your trip

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