PACS Request Form – Encapsulate

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 Email Confirm Email

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)

Images needed permanently?(Required)

Yes

What is the reason the images are required permanently?(Required)

MDT

Clinic

Review

Other

What is the reason?(Required)

You have selected Review. Images will not be kept permanently.

Whether or not images will be kept permanently will be determined on a one by one basis by Radiology IT.

Date of appointment or MDT(Required)

Reason for request(Required)

Other reason for request(Required)

Patient Date of Birth(Required)

Patient Details

Patient Name(Required)

Forename Surname

Patient HEY Number(Required)

If no HEY number is provided, the images will be deleted after 8 days.

Patient NHS Number(Required)

This is a 10-digit number.

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

Name

This field is for validation purposes and should be left unchanged.