PACS Request Form

Reference

What would you like to request?(Required)

Image Import

Image Export

CD (Hard Copy)

Your Name(Required)

Forename Surname

Your Ward / Department(Required)

Your Site(Required)

Your Email Address(Required)

Your Phone Number(Required)

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 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(Required)