PACS Request Form

Reference

Please note that imported images require 48 hours’ notice if you want them attached to the HEY number. Without 48 hours' notice you should still be able to find the images on PACS using the patients name instead.

What would you like to request?(Required)

Image Import

Image Export

CD (Hard Copy)

Your Details

Your Name(Required)

Forename Surname

Your Ward / Department(Required)

Your Site(Required)

Your NHSmail Email Address(Required)

Please note that we cannot send a confirmation to non-NHSmail email addresses.

Enter your NHSmail email address Please type it again to ensure it's correct

Your Phone Number(Required)

Request Details

Please state the full name of the trust which the images are being forwarded to, as in most cases these will now be sent electronically via IEP.

Full name of the third party trust(Required)

Third party trust patient ID (if known)

Full name of the consultant / doctor who requires the images(Required)

Speciality(Required)

Date of appointment or MDT(Required)

Reason for request(Required)

Other reason for request(Required)

Patient Details

Patient Name(Required)

Forename Surname

Patient HEY Number(Required)

Patient NHS Number(Required)

This is a 10-digit number.

Patient Date of Birth(Required)

Requests stating 'All PACS' in the Patient Examination Details field will not be accepted unless from Medical Records.

Patient Examination Details(Required)

Patient Examination Date