Diagnostic referral form - Guys and St Thomas Specialist Care

Requested procedure(Required)

Please provide details(Required)

PET-CT(Required)

Chemotherapy

Radiotherapy

Recent biopsy

None of the above

MRI(Required)

Metallic fragments in body

Cardiac pacemaker/ICD

Cochlear implant

Intracranial aneurysm clips

Other metallic implants

None of the above

CT/MRI(Required)

Reaction to contrast media

Kidney disease/surgery

Dialysis

None of the above

Last session(Required)

Next session(Required)

Please provide details(Required)

Hospital number

Name(Required)

Prefix First Last

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Gender(Required)

Male

Female

Non-binary

Prefer not to say

Date of birth(Required)

Email(Required)

Telephone(Required)

Weight

Interpreter required

Yes

No

Language required

Payment details

Payment provider

Please provide details

Clinical indication for examination(Required)

Please summarise relevant history, clinical findings, and previous test results. Please indicate the question that the examination aims to answer.

Previous imaging/ reports file

Max. file size: 128 MB.

Name(Required)

First Last

GMC(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone

Email(Required)

Signature(Required)

Date(Required)

CAPTCHA

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First Choice

Second Choice

Third Choice