X ray referral form 2026

1. Click ‘Get Form’ to open the X-Ray Referral Form in the editor.
2. Begin by entering the patient's details, including NHS Number, Forename, Surname, and Address. Ensure all fields are filled accurately for proper identification.
3. Fill in the Date of Birth and both Home and Work Telephone numbers. This information is crucial for contacting the patient if necessary.
4. Next, complete the Referrer section with your Name, GMC/HPC/NMC Number, and Address. Include your CCG Code and Practice Code for administrative purposes.
5. Provide your contact details including Telephone No., Mobile, E-mail Address, and indicate Gender. If applicable, specify any physical or communication difficulties.
6. In the Presenting Complaint & Provisional Diagnosis section, provide detailed clinical information to ensure appropriate investigations are performed.
7. Select the required investigations by ticking the relevant boxes for each body part. Indicate left (L) or right (R) where necessary.
8. If applicable, answer questions regarding pregnancy and provide the date of the last menstrual period.
9. Finally, sign the form as a referrer to comply with regulations before submitting it via post, fax, or email.

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