X-ray Self-Referral Form

Complete all sections below. The form will be sent to our clinical team and a copy emailed to the patient.

599–613 Princess Road, Dartford, Kent, DA2 6HH

01322 914330

[email protected]

Section 1 — Patient Details

Title*

First Name*

Last Name*

Date of Birth*

Sex*

NHS Number

Phone Number*

Email Address*

Home Address*

Postcode*

GP Name*

GP Practice*

GP Phone

Section 2 — Clinician Identity

Complete your professional details here first. The clinical justification section below will unlock once your name, registration body, and registration number are provided.

Title*

First Name*

Last Name*

Registration Body*

Registration Number*

Complete Section 2 to unlock

Enter your name, registration body, and registration number above before completing the clinical justification.

Section 3 — Clinical Justification

Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R): All X-ray requests must be clinically justified. The referring clinician is responsible for providing sufficient clinical information to allow the practitioner to justify the exposure.

Requested Examination*

Clinical Urgency*

Clinical Indication — Reason for Request*

Relevant Clinical History*

Current Medications*

Known Allergies*

Patient Mobility Status*

Infection / Isolation Risk*

Previous Relevant Imaging*

Additional Clinical Notes

Section 4 — Signature & Declaration

By signing this form, the referring clinician confirms that the X-ray request is clinically justified, the patient has been informed of the procedure, and all information provided is accurate to the best of their knowledge.

Electronic Signature*

Draw your signature above using mouse or touch

Signature is required

Date Signed*

Submitting will email the completed referral to [email protected] and send a copy to the patient's email address.

All required fields must be completed before submitting.

This form is for clinical referral purposes only. Radpid Diagnostics Ltd processes personal data in accordance with UK GDPR and our Privacy Policy. All referrals are subject to clinical review by our radiographers before examination.