YORK TEACHING HOSPITAL NHS TRUST 
Primary Care CT Scan Referral

Incomplete requests could delay this examination or result in an incomplete investigation

Patient Information 
Patient Name: Full Name  
NHS Number: NHS Number  
DOB: Date of Birth  
Gender: Gender  
Address: Home Full Address (single line)  
Telephone Number: Patient Home Telephone   
Mobile Number: Patient Mobile Telephone 	From April 2018 all patients needing IV contrast for CT need to have a Creatinine and eGFR no more than 3 months prior to their scan.

Please either provide the results below and date of test   
*Serum Creatinine: Single Code Entry: Serum creatinine  
  
*eGFR: Single Code Entry: GFR calculated abbreviated MDRD    

OR: Order bloods and tick the box  

Requests may not be processed until results are available to us

Consider renal prophylaxis, if creatinine > 150 μMol AND eGFR < 45 ml /min / m2

Examinations not requiring IV contrast are 
•	CT KUB
•	CT sinuses
•	CT head (unless looking for metastases)
•	HRCT of the chest
•	Orthopaedic CT
	
Examination requested (see CCG guidelines):
  
Freetext:      

Patient is on a fast track pathway  Yes		
Clinical details and diagnosis:
      

		
Diabetic? Single Code Entry: Diabetes mellitus    
Is the patient on Metformin? 
Yes  No 
If diabetic and on metformin, please ensure creatinine & eGFR (<3 months old) are provided.
	
 This request been discussed with a consultant? 
Who?      
 This test is part of a CCG approved pathway
Which one?      
 This test has been suggested by a specialist team
Who?      
	Possible pregnancy?

Disability? Yes 
Hearing  Visual  Learning 

Please describe mobility:
Walking  Trolley  Chair 
Bed  Hoist  O2           	
Weight: Single Code Entry: O/E - weight    	
Referring Clinician Requests only accepted from Trust approved referrers - Ionising Radiation (Medical Exposure) Regulations 2000

GP Name : Current User  
GP Practice: Organisation Name  
GMC Registration Number / NMC short code Free Text Prompt  (compulsory for email requests)
Date of referral: Short date letter merged     	

PATIENT ID LABEL HERE

For Radiology Use Only	                                               Urgent ☐  Soon ☐  Routine ☐  

Authorised by: 		                  Practitioner:                           Operator:                                                                  
Scan type:		
Comments:

IV Contrast:  Y ☐ N ☐			      Oral Contrast:  Y ☐ N ☐

Oral Prep         	Volume:   500ml      /        1000mls       /      800mls       
         Omnipaque 350 ☐   
         Gastrografin       ☐        
         Water                 ☐                        
         Klean Prep         ☐           
         EZ CAT              ☐                    

Radiology appointment date & time:	
For Radiology Use Only	
ID check
Name  ☐  DoB  ☐   Address  ☐   Wristband  ☐
ID checked by - Name of Staff:  

Operator:                                          Room:                                   Dose:                 mAs*  mGy.cm²*
                                                                                                                                                                                                                            (* Please circle as appropriate)
Pregnancy Status
There is no possibility that I am pregnant (signature):                                              Date: 
1st day of LMP:                                                  THE 10/28 DAY RULE APPLIES
Checked by (staff):                                             Date: 
Decision to over-rule (Dr):                                  Reason:	
Oral contrast check

Name  ☐  DoB  ☐ allergies ☐ omnipaque ☐           kleanprep ☐  ezcat ☐  water   ☐   gastrografin ☐  
Vol given by:
500 / 1000 /  800mls	IV contrast and buscopan check
allergies*   ☐  asthma ☐  diabetic ☐ metformin ☐  
hyperthyroidism ☐ buscopan ☐   mys gravis ☐  
heart / bp ☐  glaucoma ☐   bladder outflow ☐      
obstruction ☐  
Agent:                             lot no:       
Given by:	
*Comments (including details of patient allergies): 	

CT appointments: York: (01904) 725936 ext.  5936 	Scarborough: (01723) 342044 ext 2044