RADIOLOGIE OENSINGEN AGOstringstrasse 17 · 4702 Oensingen062 530 17 50 · radiologie.oensingen@hin.chwww.radiologie-oensingen.ch
Referral form
Please complete all fields and send only through an agreed secure channel.
Patient
Surname
First name
Date of birth
Street
Postcode / Town
Telephone / Mobile
Email
Insurer / Payer
AHV no.
Insurance / Accident claim no.
Card no. (optional)
☐ Illness☐ Accident☐ Self-paying☐ Please contact the patient to arrange an appointment
Date of accident (if applicable)
Appointment & requested examination
Appointment requested no later than
Confirmed appointment – date
Time
☐ MRI☐ CT☐ Osteo-CT (bone density)☐ Ultrasound☐ X-ray☐ Other
Body region / Side
Clinical information
Indication / Clinical information / Relevant medical history
Clinical question
Relevant previous examinations / Operations
RADIOLOGIE OENSINGEN AGOstringstrasse 17 · 4702 Oensingen062 530 17 50 · radiologie.oensingen@hin.chwww.radiologie-oensingen.ch
Safety information
Pregnancy☐ Yes☐ No
Creatinine / eGFR with date, where required
For MRI and examinations with contrast medium, please answer each question with Yes or No.
Pacemaker / ICD☐ Yes☐ No
Implant / Metal / Foreign body☐ Yes☐ No
Contrast medium reaction / Allergy☐ Yes☐ No
Kidney disease☐ Yes☐ No
Thyroid disease☐ Yes☐ No
Diabetes☐ Yes☐ No
Claustrophobia☐ Yes☐ No
Tattoo less than 6 weeks old☐ Yes☐ No
Details of Yes answers / Implants / Allergies / Relevant medication
Referring clinician or practice
Practice / Institution
Doctor
Direct telephone
Address
Postcode / Town
Email / HIN address
Report copy☐ Yes☐ No
Report copy to
Place / Date
Signature / Practice stamp