‫المملكة العربية السعودية‬

Kingdom of Saudi Arabia ‫وزارة الصحة‬

Ministry of Health ‫المديرية العامة للشئون الصحية بمنطقة الرياض‬
Directorate General of Health Affairs Riyadh Region ‫مجمع إرادة للصحة النفسية بالرياض‬
‫مركز االحاالت الطبية‬
Eradh Complex of Mental Health ‫قسم أهلية العالج والتنسيق الطبي‬
Medical Referral Center
Department of Eligibility for Treatment and
CT REQUEST FORM
Patient’s Name: Ward/Clinic:
Nationality: Hospital No:
SEX:
Age:

*Pls, check for possible hazard: (YES) or (NO)

Pregnancy Cardiae Pacemaker

Surgical Clips Intracranial Vascular Clips

Artificial Heart Valves Intraocular Metallic F .B

Joint Prosthesis , Fixation Material Nail, Plate etc.
IF yes, Please specify whether it is MRI Compatible or Not
Previous surgery (please specify)
IF there is any medical illness (specify)
Level of urea: mmol/l Level of creatinine : umol/l

Examination Requested:

Clinical Details and Provisional Diagnosis:

Treated Consultant Signature/Stamp: Date: / /

Bleep #
Technologist Name: No. of Films Appointment on:
Date: / /

-This form must be completed by the referring clinician (specialist / Consultant) related to his specialty who is responsible for ensuring that the details
are correct Failure to comply may result, in the patient’s safety being compromised.

-patient to bring all related previous X-Rays and Reports.