Department of Diagnostic Imaging

                                               St. Vincent’s Private Hospital

                                                                          Referral Form

Surname: First Names:	Date of Birth          /      / Sex    Male   Female 
Address:	Tel.: No.: Mobile Number Hospital Reg. No    Prev. Exam  Yes      No  
Clinical Indications: Questions you need answered / Working diagnosis and possible alternatives. 1. 2. Previous Surgery:-
Medico Legal     Yes      No  
Examination Required:		Chair          Stretcher     Portable      Theatre       Walking     
Is the patient receiving treatment for diabetes?                         Yes       No     Does patient have history of renal disease?                               Yes       No     If yes to either of these questions have any recent blood tests been performed? Yes       No    Serum Creatinine (If known)________________               Date
(For completion by patient) Are you pregnant?      Yes      No   Date of LMP Patient’s Signature
MRI SCANS Please note that the following are contra-indications for MRI scanning: Pacemakers, Aneurysm clips, Intra-orbital metallic foreign bodies
FOR MEDICO LEGAL REASONS ALL CARDS MUST BE SIGNED BY DOCTOR / DENTIST
Referring Doctor: Address: Signature:                                                                                Date: Phone:                                                                      Fax.:
For Department Use Only

       (This form can be downloaded from the radiology page or our website <www.svph.ie> for printing)