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)
Should echinacea be taken on a daily basis?The question whether echinacea should be used on along-term or continual basis has not been adequatelyanswered. The usual recommendation with long-termuse is 8 weeks on followed by one week off. Researchsuggests that the people most likely to benefit fromusing echinacea for prevention are those with weakerimmune systems who are more prone to infection.
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
Easy Imaging Ltd