Patient Referral Form

Suitability for Cancer Screening

Cancer screening scans aren't suitable for everyone. It is for early detection of cancer in clients who do not have symptoms. If you do have one or more of the following signs and symptoms please contact your GP. If you do not have any to the following signs and symptoms you will be asked additional health screening questions later in the form so we can ensure this is the right scan for you.

General cancer symptoms: (Cancer Research UK, 2024)

Very heavy night sweats or fever Sweating at night or having a high temperature (fever) can be caused by infections or a side effect of certain medications. It’s also often experienced by women around the time of the menopause. But speak to your doctor if you have very heavy, drenching night sweats, or an unexplained fever.
Fatigue There are lots of reasons why you may feel more tired than usual, particularly if you’re going through a stressful event, or having trouble sleeping. But if you’re feeling tired all the time, or, for no clear reason, it could be a sign that something is wrong - speak to your doctor.
Unexplained bleeding or bruising Unexplained bleeding or bruising when you have not hurt yourself is important to get checked out by your doctor. This includes blood in your poo or pee, as well as vomiting or coughing up blood. It also includes any unexplained vaginal bleeding between periods, after sex or after the menopause. No matter how much blood or what colour it is (blood can be red, or a darker colour like brown or black), speak to your doctor.
Unexplained pain or ache Pain is one way our body tells us that something is wrong. As we get older, it’s more common to experience aches and pains. But unexplained or persistent pain anywhere in the body could be a sign of something more serious.
Unexplained weight loss Small weight changes over time are quite normal, but if you have lost a noticeable amount of weight without trying to, tell your doctor.
Unusual lump or swelling anywhere Persistent lumps or swelling in any part of your body should be taken seriously. This includes any lumps in the neck, armpit, stomach, groin, chest, breast, or testicle.

Do you currently have any symptoms listed above?

Personal Information

Full Name

First

Last

Date of Birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GP details

GP Name

First

Last

GP's Email address

GP’s Contact number

GP Practice name

GP Practice Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

	Yes	No
Heart surgery, e.g. bypass or valve surgery	YesHeart surgery, e.g. bypass or valve surgery Yes	NoHeart surgery, e.g. bypass or valve surgery No
Brain surgery, e.g. shunts, clips on blood vessels or blood clots removed	YesBrain surgery, e.g. shunts, clips on blood vessels or blood clots removed Yes	NoBrain surgery, e.g. shunts, clips on blood vessels or blood clots removed No
Eye surgery, e.g. cataracts or retinal tack	YesEye surgery, e.g. cataracts or retinal tack Yes	NoEye surgery, e.g. cataracts or retinal tack No
Ear surgery, e.g. stapedectomy	YesEar surgery, e.g. stapedectomy Yes	NoEar surgery, e.g. stapedectomy No
Any fragments of metal gone into your eyes?	YesAny fragments of metal gone into your eyes? Yes	NoAny fragments of metal gone into your eyes? No
Any bullet or shrapnel injuries?	YesAny bullet or shrapnel injuries? Yes	NoAny bullet or shrapnel injuries? No
Any metal or electronic implants, or fixed electronic devices, e.g. diabetes monitoring patches, joint replacements, pins, clips, plates or screws, neurostimulator, cardiac recorder ("reveal device")	YesAny metal or electronic implants, or fixed electronic devices, e.g. diabetes monitoring patches, joint replacements, pins, clips, plates or screws, neurostimulator, cardiac recorder ("reveal device") Yes	NoAny metal or electronic implants, or fixed electronic devices, e.g. diabetes monitoring patches, joint replacements, pins, clips, plates or screws, neurostimulator, cardiac recorder ("reveal device") No
Swallowed a "PillCam" camera tablet to investigate your bowel	YesSwallowed a "PillCam" camera tablet to investigate your bowel Yes	NoSwallowed a "PillCam" camera tablet to investigate your bowel No
Any cosmetic procedures done? e.g. breast / penile implants, hair extensions,	YesAny cosmetic procedures done? e.g. breast / penile implants, hair extensions, Yes	NoAny cosmetic procedures done? e.g. breast / penile implants, hair extensions, No

	More than 12 months ago	Within 12 months	No	Don't know
Whole body MRI	More than 12 months agoWhole body MRI More than 12 months ago	Within 12 monthsWhole body MRI Within 12 months	NoWhole body MRI No	Don't knowWhole body MRI Don't know
Other Imaging tests	More than 12 months agoOther Imaging tests More than 12 months ago	Within 12 monthsOther Imaging tests Within 12 months	NoOther Imaging tests No	Don't knowOther Imaging tests Don't know
Mammography	More than 12 months agoMammography More than 12 months ago	Within 12 monthsMammography Within 12 months	NoMammography No	Don't knowMammography Don't know
Cervical screening	More than 12 months agoCervical screening More than 12 months ago	Within 12 monthsCervical screening Within 12 months	NoCervical screening No	Don't knowCervical screening Don't know
Faecal blood test	More than 12 months agoFaecal blood test More than 12 months ago	Within 12 monthsFaecal blood test Within 12 months	NoFaecal blood test No	Don't knowFaecal blood test Don't know
Colonoscopy	More than 12 months agoColonoscopy More than 12 months ago	Within 12 monthsColonoscopy Within 12 months	NoColonoscopy No	Don't knowColonoscopy Don't know
PSA test	More than 12 months agoPSA test More than 12 months ago	Within 12 monthsPSA test Within 12 months	NoPSA test No	Don't knowPSA test Don't know
Other screening tests	More than 12 months agoOther screening tests More than 12 months ago	Within 12 monthsOther screening tests Within 12 months	NoOther screening tests No	Don't knowOther screening tests Don't know

	Yes	No	Don't know
Mother	YesMother Yes	NoMother No	Don't knowMother Don't know
Father	YesFather Yes	NoFather No	Don't knowFather Don't know
Brother	YesBrother Yes	NoBrother No	Don't knowBrother Don't know
Sister	YesSister Yes	NoSister No	Don't knowSister Don't know
Maternal grandmother	YesMaternal grandmother Yes	NoMaternal grandmother No	Don't knowMaternal grandmother Don't know
Maternal grandfather	YesMaternal grandfather Yes	NoMaternal grandfather No	Don't knowMaternal grandfather Don't know
Paternal grandmother	YesPaternal grandmother Yes	NoPaternal grandmother No	Don't knowPaternal grandmother Don't know
Paternal grandfather	YesPaternal grandfather Yes	NoPaternal grandfather No	Don't knowPaternal grandfather Don't know
Additional relative	YesAdditional relative Yes	NoAdditional relative No	Don't knowAdditional relative Don't know

Eligibility Checks

Suitability for Cancer Screening

General cancer symptoms: (Cancer Research UK, 2024)

Scan Type

Wholebody MRI Safety screening

Liver MRI Safety screening

Personal Information

GP details

Health Screening

Health Screening

General Questions

Liver Scan Questions

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