Fax Back Form to 01432 364015

 

Or post to:

Department of Radiology

 

County Hospital

 

Hereford

 

HR1 2ER

Tel:

01432 364454 (direct dial private patient line)

 

 

Hereford Radiology Group: Private CT / US / Plain Film Request

Appointment date and time

 

Hereford Unit Number (if known)

Investigation Requested*

 

 

Surname*

 

Forename*

 

DOB*

SEX: M / F

Clinical Details/Suspected diagnosis*

 

 

 

 

 

 

Patient wt:

LMP date:

Address*

 

 

Post code*:

Phone number*

Home

Work

Mobile

Insured

 

Self-pay

Medico-legal

Cat II

 

Referrers contact details (or practice stamp)

Address*:

 

 

Phone number*:

 

Fax number (will be used to issue report)*:

Name of Referrer*

 

 

Referrer Signature*

 

Date*:

 

Office use: Justified by:

* Denotes mandatory information.

 

 

 

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