Camden Non- Contrast CT KUB Referral Form
UCLH operates a CT walk-in clinic at Westmoreland Street London.  The opening times are from Monday to Friday from 09:00-16:00
For UCLH email the form to: ucl-tr.UCHRadiology@nhs.net and give the patient a copy to take to the CT walk in Centre
at 16-18 Westmoreland Street, Marylebone, London, W1G 8PH
For RFH email the form to rf.radiologyenquiries@nhs.net 
UCLH operates a walk-in service Westmoreland street, London.  The opening times are from 09:00-16:00
Patient’s Details
Surname: Surname 
First names: Given Name 
Address: Home Address Number and Street, Home Address County, Home Address Town 

Postcode: Home Address Postcode 	NHS Number: NHS Number 
DOB: Date of Birth 
Gender: Gender                                                            
Interpreter required: Interpreter required  
Language: Main Language 	
Telephone Number (s)
Home: Patient Home Telephone 
Work: Patient Work Telephone 	Mobile: Patient Mobile Telephone 
E-mail: Patient E-mail Address 	
Exclusion Criteria (ADMIT PATIENT)
•	Shock, fever or other signs of systemic infection
•	At increased risk from loss of renal function e.g. solitary or transplanted kidney, pre-existing renal impairment, bilateral obstructing stones suspected 
•	Not responding to analgesics/anti-emetics and within 1 hour or recurrence of severe pain despite analgesia
•	Dehydrated or unable to tolerate fluid due to vomiting
•	Uncertainty regarding diagnosis including risk of ectopic if delayed period, >60 yrs esp. male with left sided pain  re risk of misdiagnosing leaking AAA
•	Pregnant women
•	Lack of home support etc.	
Confirm pregnancy status of patient (please Tick)	
YES 	NO 	UNSURE 	NOT APPLICABLE    		
Do not Proceed	Proceed if no other exclusion criteria met	Is today within the first 10 days of the patients’ menstrual cycle?	OK to proceed if no other exclusion criteria are met		
		YES 	NO 			
		Proceed if no other exclusion criteria met	Can pregnancy be excluded?			
			Yes 	No 			
			Proceed if no other exclusion criteria met	Do not Proceed			
Inclusion Criteria (GP management suitable)
•	16-60yrs  ● Diagnosis consistent with ureteric colic ● Pain responds to analgesics
•	Adequate home support  ● Telephone contact possible	
Referral Information:
    
Consultations 

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Referring Doctor’s Name: Referring User 
GP Surgery: Organisation Name 
Address: Organisation Full Address (single line) 
GP GMC Number: Free Text Prompt :  

Email Address: Organisation Fax Number 
Tel: Organisation Telephone Number 
Referral date: Short date letter merged                                                               Signature: Free Text Prompt