Scan Urgency: Routine [ ] Urgent [ ]

Patient full GAVRILA, Cristina (Mrs) Male: [ ]

nam e Female: [ ]
NHS Number: 718 642 3361 D.O.B: 02-Apr-1980
Address: 111 Darlaston Road Tel: 07445820949
Walsall
West Midlands
WS2 9RD
Town : Walsall Mobile: 07445820949
Post code: WS2 9RD Email:

Primary Care Trust The Saddlers Health GP Practice Details: The Saddlers Health
name Centre Centre
Referring GP Practice Dr M Verma, Dr F Address: 1 Hatherton Street
Number Mahmood
Referrer’s Name: Dr F Mahmood DR M
Verma
GP/GPSI Nurse/AHP: GP
Clinical summary/ reason for request : Postcode: WS1 1AF
Tel: 01922 622326
Fax: N/A
Email: Clinicalinfo.m91018@nhs.net

Abdomen Shoulder Other

Pelvis Elbow
Urinary Tract (KUB): Hand/Wrist
KUB & Prostate: Hip
Transvaginal: Knee
Testes: Ankle
Lumps & Hernia: x Foot

Special Patient developed lump over rt shoulder blade for

Requirements: last 1-2 months ? lipoma
Mobility assistance: Sensory impairment:
Interpreter Required [ ]Yes No If Yes, please specify
[ ] language
Any other relevant
information
concerning the patient

Please note we are unable to accept ultrasound referrals for following categories:
Any request for 2 week wait investigations
Thyroid
Breast
UNDER 18 years old
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REV 4.0