01322 914330
Radpid Diagnostics — Point of Care Medical Imaging
From: Radpid Diagnostics <[email protected]>
Subject: X-ray Referral — Mr James Thornton — Lumbar Spine X-ray
Date: 03 July 2026, 14:22
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Radpid Diagnostics Ltd

X-ray Self-Referral Form

599–613 Princess Road, Dartford, Kent, DA2 6HH  |  Tel: 01322 914330  |  [email protected]
Ref: RD-XR-2026-914330Generated: 03 July 2026Status: Pending Clinical Review
Section 1 — Patient Details
Full NameMr James Thornton
Date of Birth14 March 1958
SexMale
NHS NumberNot provided
Phone07700 912 345
Email[email protected]
Address42 Orchard Lane, Dartford, DA1 3PQ
GP NameDr Sarah Patel
GP PracticeDartford Health Centre
GP Phone01322 555 100
Section 2 — Clinical Justification
Requested ExaminationLumbar Spine X-ray
Clinical UrgencyRoutine (within 5 working days)
Clinical IndicationPatient presents with a 6-week history of lower back pain radiating to the left leg. Symptoms worsened following a fall at home. Query degenerative disc disease vs. compression fracture. Requesting AP and lateral lumbar spine views.
Relevant Clinical HistoryKnown osteoporosis (diagnosed 2019, on alendronate). Previous L4/L5 disc prolapse 2014 managed conservatively. No previous spinal surgery. Hypertension — well controlled on ramipril.
Current MedicationsAlendronate 70mg weekly, Ramipril 5mg OD, Paracetamol 1g QDS (for pain)
Known AllergiesPenicillin (rash)
Mobility StatusPartially mobile — requires assistance
Infection / Isolation RiskNone
Previous Relevant ImagingMRI lumbar spine — June 2014 (L4/L5 disc prolapse, no cord compression). No imaging since.
Additional NotesPatient is anxious about the procedure. Please allow extra time for positioning.
Section 3 — Clinician Sign-off
Clinician NameDr Amelia Hartley
Registration BodyGMC — General Medical Council
Registration NumberGMC 7654321
Date Signed03 July 2026
Electronic SignatureElectronic signature
Declaration: By submitting this form, the referring clinician confirms that the X-ray request is clinically justified under IR(ME)R 2017, the patient has been informed of the procedure, and all information provided is accurate to the best of their knowledge.
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