MRI REFERRAL FORM (Bariatric/Claustrophobic Service) - Open Scanner
Barnet Borough of NCL CCG
Please note: this service does not accept urgent referrals.  All referrals are booked in and treated as routine.
Please note – we are unable to accept referrals for breast MRI

Symptoms indicative of / suspected Cauda Equina?

                 Yes                                                                                      No    

Please note – we are unable to accept referrals where cauda equina syndrome is the working diagnosis of or suspected by the referrer or in patients where the symptoms are indicative of it. Please redirect any referral to the appropriate provision	

Section 1 - Information Governance Statement
This application form and any other supporting information supplied may be shared with the CCG or other trusted organisations legitimately acting on behalf of the CGG.  Personal information may be retained only for the purposes of this and, in some cases, may be used for invoicing and payment reconciliation. Anonymised information may also be shared as part of CCG reporting processes.	

PLEASE SIGN BELOW TO INDICATE THAT YOU:
Have discussed the information governance statement above with your patient and that they give their consent for information about their case to be used to process their application in accordance with the provisions of that statement.

Applicant’s signature
Signed by:  ……………………………………………..…….. Date signed: Short date letter merged 
Print name: Current User        GMC No:      
All forms must be signed by the NHS Practitioner (unsigned forms will not be accepted)	

This form should be sent from an nhs.net secure email account to:        
Barnet-routine.referrals@nhs.net 
Requested/Additional information referrals: Barnet-requested.information@nhs.net 

Please call 0208 865 2040 if you need support to complete this form.	

Quality of imaging
Please tick to confirm that you have explained to the patient that an open MRI provides a poorer quality image compared to standard MRI and therefore subtle abnormalities are likely to be missed. Only tick if the patient is fully aware prior to requesting a MRI.	Please tick to confirm
	
Section 2 – Does the patient meet the Open MRI interim criteria?

The expected pathway for patients with claustrophobia is that there is documented evidence of the criteria below. Please confirm yes or no that these criteria have been met		
1.	patients failing to tolerate a standard MRI have been offered a standard MRI with oral sedation 
	 Yes, please provide details below
 No
	
2.	The requested scan is for the head/ neck/ thorax/chest/abdomen

(Any scans below the hips/lumber spine can be done in a conventional MRI scanner)
	 Yes, please provide details below
 No
	
3.	The (width) measurement of the patient at their widest point is not greater than 27 inches / 70cm	 Yes, please provide details below
 No
	
4.	The applicant can confirm that alternative diagnostic tools such as Xray or ultrasound are inappropriate for securing differential diagnosis.	 Yes, please provide details below
 No

Main reason for referral:   Bariatric   Claustrophobic 
Please ensure these criteria are considered before referring a patient
1.	Has the patient attempted a scan in a conventional scanner with InHealth?
2.	Patient is over 21st (135kg) please indicate height and weight below? (open scanner table limit 47st)
3.	Have other options been considered for Claustrophobic Patients?
a.	Oral sedation?
b.	Feet first into scanner (L-spine, knees and feet)?
c.	Is the patient able to travel independently to an Open MRI Scanner?
d.	Are other diagnostic tests available?	
YesNo
YesNo

YesNo
YesNo
YesNo
YesNo	

Please include any information that will assist with the management of this patient	
PATIENT	REFERRER	
NHS Number	NHS Number 	Name	Current User 	
Forename	Given Name 	GMC/HPC/NMC No		
Surname	Surname 	Address	Organisation Full Address (single line) 	
Address	Home Full Address (single line) 			
Date of Birth 
(0ver 18 only)	Date of Birth 	Referring CCG Code		
Telephone (Home)	Patient Home Telephone 	Referring Practice Code	Organisation National Practice Code 	
Telephone (Work)	Patient Work Telephone 	Telephone No.         
(for urgent clinical findings)	Organisation Telephone Number 	
Telephone (Mobile)	Patient Mobile Telephone 	Fax No.	Organisation Fax Number 	
E-mail Address	Patient E-mail Address 	NHS.net mail only	Organisation E-mail Address 	
Gender	Gender(full) 	If interpreter required, language: Main Language 	
Physical/Communication difficulties (specify if any): 	Height: Height 	
Ethnicity: Ethnic Origin 	Weight: Weight 	
PRESENTING COMPLAINT & PROVISIONAL DIAGNOSIS
Please provide as much relevant clinical information as possible to assist with the interpretation of the referral and images. 	
Investigation(s) Required: please indicate which side of body and body part where appropriate.
	
What is the patients’ presenting complaint?
Consultations 
	
How long has the complaint been persisting?
	
What treatment/management of the condition has been provided?
	
What is the clinical question you require us to answer?

Please tick box if this scan is related to recent (within 5 years) spinal or neurosurgery 	
All referrers must complete the following MRI safety questions:
1.	Does the patient have any implanted metallic foreign devices? (e.g. cardiac pacemaker, artificial heart valve, cerebral aneurysm clips, cochlear implant etc)

2.	Is the patient known to have metallic fragments in their eyes?

Date of Referral : Short date letter merged 	Yes      No  

Yes      No  	

	
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Version: June 2021