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Health Professional

REFERRAL
IMAGING REFERRALSOur Treatments

IMAGING REFERRALS

Patient Referral
Health Professional Referral

The clinic provides healthcare professionals with fast and competitively priced x-ray and MSK Diagnostic Ultrasound imaging. Evening and weekends available. We offer appointments from the same day and a report turn around within 48 hours (24 hours can often be achieved).

Musculoskeletal Ultrasound £155 per region
X-rays from £75
Ultrasound Guidelines
  1. Please complete the following form including clinical details to aid diagnosis.
  2. Once received our reception team will contact your patient to organise the most convenient time for them to attend.
  3. We will email your report to you through the email address you provided on your referral form.
Ultrasound Guidelines
ULTRASOUND REFERRAL FORM
ADDRESS:
PATIENT TELEPHONE NUMBERS:
SCAN INFORMATION:
CLINICAL HISTORY:
RELEVANT PREVIOUS IMAGING RESULTS:
REFERRING PRACTITIONER/CLINICIAN/GP:
PRACTICE ADDRESS:
PRACTICE CONTACT DETAILS:
Digital X-Ray Guidelines
  1. The first time you refer a patient for x-ray we require you to complete the statement of referring health professional form. Please download this pdf, sign and return to us at:

    info@chelmsfordchiroclinic.co.uk
    or
    Chelmsford Chiropractic Clinic
    5 First Avenue
    Chelmsford
    Essex
    CM1 1RX
  2. Please only complete and return this form once to register yourself.
  3. Please only complete and return this form once to register yourself.
  4. Please complete the online X-ray request form including clinical details and the email address you would like the report sent to.
  5. Once received our reception team will contact your patient to organise the most convenient time for them to attend.
  6. We will email your report to you through the email address you provided on your referral form.
  7. X-ray fee: £75 = 1 area, + £30 for each additional area. 
     
    Optional report fee: £20 = (x1 area), £30 (for more than x1 area). 
Digital X-Ray Guidelines Statement of referring health professional
ONLINE X-RAY REFERRAL FORM
ADDRESS:
PATIENT TELEPHONE NUMBERS:
X-RAY INFORMATION:
CLINICAL HISTORY:
The patient meets the following criteria
Trauma
Neurological deficit
Surgery
Scoliosis
Age over 50
Pyrexia
Drug/Alcohol abuse
Failure to improve with conservative treatment
Equivocal biomechanical findings
Investigation of extreme postural anomaly
Unexplained weight loss/malignancy
Inflammatory arthopathy
History of use of steroids
Clinical examination limited by pain
CLINICAL QUESTION TO BE ANSWERED / REASON FOR TAKING THE X-RAY:
X-RAY REPORT REQUEST:
Do you require an x-ray report?
Yes
No
ADDITIONAL INFORMATION FOR THE REPORTING RADIOLOGIST:
History of cancer?
Yes
No
(Specific type, year of diagnosis and therapy)
REFERRING PRACTITIONER/CLINICIAN/GP:
PRACTICE ADDRESS:
PRACTICE CONTACT DETAILS:
IMAGING CONSIDERATIONS:

In all women of reproductive capacity, the clinician should consider the possibility of an early pregnancy. For most examinations, the risk to the foetus is negligible during the first 28 days following commencement of the last period.

Upon arrival into the imaging department you will be asked to sign this referral to confirm your pregnancy status.

Exposure to Ionising Radiation Regulations: The Referrer requesting the X-ray examination must be satisfied that it is necessary and that it will directly affect patient management. It must be ensured that the investigation has not already been carried out at this clinic or elsewhere. Any proposed deviation from the current Royal College of Radiologists guidelines must be discussed with a radiologist. Each request must be completed by a suitably qualified practitioner who must have signed and successfully returned a statement of referring practitioner form? prior to the request being sent.

PRACTITIONER CONSENT:
Can you confirm you have completed an updated IR(ME)R training course in the past 5 years. Please note that you will be required to provide evidence of this.
Yes
No
I give my consent to this x-ray request form and I agree that I have completed, signed and returned the 'Statement of health care professional referring patients for X-ray to Chelmsford Chiropractic Clinic Ltd' document and understand that I must complete the x-ray request form myself or it will be considered a breach of the law.
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