Referring Physician Details
Name:*

Hospital/Clinic:*

Email:*

Contact No:*

Country:*

Patient Details
Name:*

Age:*

Gender:*

Male Female

Nationality:*

Parent/Guardian Details
Name:*

Contact No:*

Email:*

General Radiology – No Appointment Needed – Walk-Ins Welcome
Requested Examination is
Chest Skull Abdomen Extremity: Right or Left or Specific region:

Spine: Specify region

Other: Specify region
Ultrasound
Renal Head Testicular Abdomen
Doppler: Specify region

Other: Specify
Fluoroscopy
Upper GI (Stomach) Upper GI with Small Bowel Colon (Barium Enema) VCUG
Other
*CT Scan – Specific Body Part
CT Scan of
* MRI/MRA Scan – Specific Body Part
MRI Scan of

MRA Scan of

Complete mri order questionnaire on page 3 for all mri studies.
Intravascular Contrast Screening Form

The Department may contact you for additional information to assist in scheduling the exams if answering yes to any of the following questions:

Have you ever had Asthma?
Yes No
Are you allergic to any drug or food (especially iodine or seafood)?
Yes No
Have you ever had an injection of contrast media before?
Yes No
Have you ever had a reaction to contrast media before?
Yes No
Are you pregnant or breast-feeding?
Yes No
Are you taking any medications for Diabetes Mellitus especially Metformin?
Yes No
Do you have any of the following conditions: Multiple Myeloma, Liver Failure, Sickle Cell Anaemia, Hepatitis, or Hyperthyroidism?
Yes No
Are you being treated for Kidney disease?
Yes No
Urea:
Date of result:
Creatinine:
Date of result:
Mri Order Questionnaire Form

The Department may contact you for additional information to assist in scheduling the exams if answering yes to any of the following questions:

Does the patient have dental hardware? (not including fillings)
Yes No
Does the patient have a ventricular shunt?
Yes No
Does the patient have a programmable CNS shunt?
Yes No
Does the patient have a VNS (Vagal Nerve Stimulator)?
Yes No
Does the patient have cochlear implants?
Yes No
Does the patient have a cardiac pacemaker?
Yes No
Does the patient have any metal inside due to surgery or injury?
Yes No
Does the patient have an artificial heart valve?
Yes No
Does the patient have any electronic devices such as neurostimulators or infusion pumps?
Yes No
Does the patient have a tracheostomy or on a ventilator?
Yes No
Does the patient have an ICD (Internal cardiac defibrillator)?
Yes No
Is this exam part of a research study?
Yes No
Special request/ Comment:

Al Jalila Children's Specialty Hospital

Al Jaddaf - Dubai
United Arab
Emirates