VCL Request Form

About the patient being referred
Patient ID (use QR Code Reader if patient ID label exists) alternatively move to next field
Name of patient*

First NameLast Name
Date of Birth of patient*

DayMonthYear
For new patients to VCL ideally include some extra information about your patient such clinical notes/GP referral letter/ summary record/front sheet/medication

Add now (most expedient)Get later (takes a bit longer to arrange tests)
Upload screenshot of Pt info - eg clinic letter or front sheet

Browse Files

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Take Photo and upload Pt info
Patient Mobile number (no country code) for our schedulers to contact patient*
If no mobile click on next box
Country Code*
44 is default
Other ways (eg land line or email of patient or next of kin) for our schedulers to contact patient
eg email or landline- Please check this is accurate-we will then message patient to get in touch and get email
What tests or services
What service or tests are being requested (tick any that apply)*

CT scan(s)MRIEchocardiogramOther
For GP RACPC referrals we require a very short few lines on reason(s) for referral and/or any symptoms/ risk factors of concern, to assist triage process.
eg "odd chest sensations Father had MI aged 50, smoker".
Short Cut?*

I’m crazily busy just now, email or print out the request form for me to complete later!I will complete form minimum dataset now (can take 45-60 seconds)
GP CT tests

CT HeadCoronary Calcium ScoreOther
Which body parts to be CT scanned? - type out or click on selected

List a combinationHeadNeckCTCA and or CACOther Thoracic scansAbdomenPelvisLegs
what CT(s) are required?
Thorax: what part(s) to be CT scanned?

CT Pulmonary Angiogram (CTPA)ECG Gated CT Aorta with measurementsLung fine slice HRCTCT Chest (inc lung nodules)TAVI CT ECG gated (whole aorta)Other tests
Cardiac CT

Coronary calcium scoreCoronary tree (CTCA)Bypass grafts (CTCA and Internal mammary and asc aorta wider FOV)LV gram (requires retrospective scan more radiation)Aortic valve assessmentFull retrospective studyNon contrast CTAs specified below
What scans?
VCL can undertake an additional ECG gated Calcium score CT (a second 120 KV scan, 1-3 mSv); indicated in addition to CTCA or non ECG gated chest CT under certain circumstances: please select one or more justification(s) below. If none are selected a CAC will only be undertaken if CTCA is requested and proves technically impossible.

The stratification of future CHD risk, not possible from CTCA/lung CT alone (ie which centile, and thus future cardiac risk ) justifies the extra radiation from an additional calcium score scanBecause of the possibility of a non-diagnostic or reduced quality CTCA (AF, ectopics, BB intolerance, increased BMI) a calcium score scan should be undertaken in addition to CTCA in order to assist with accurate diagnosis.there has been no previous raised calcium score done, to assist with risk stratification'Catch-all' - patient over 40 yrs under chest team investigation, to include coronary screening.CAC not required in this caseOther
Do you have a preferred faculty Radiologist/Cardiologist to oversee this referral?

No, any faculty member can overseeAs per agreement for my membershipI would like a particular faculty member to oversee and where possible/feasible report the test(s)
Preferred Consultant to oversee (justify and or report) are

Duty Cardiologist or RadiologistELPCMHAHMIEWZZTMSRJSMFJDOther
Do you have a preferred faculty member to report cardiac structures (sent to pool if not reported within 24 hours of scan) ?

ELMHSRJSAHMIEWOther
Non cardiac: what part(s) to be scanned

CT renal arteriesCT descending aortaCT abdomenCT PelvisCT Whole urinary tractCT Iliacs and whole leg vesselsCT headCT angio CarotidOther
Medics: which body parts to be MRI scanned? - type out or click on selected

HeadCarotids with contrastNeckCardiac structuralCardiac late gad (scar)Cardiac perfusion rest and stressThoracic aorta and archAbdominal aorta (contrast)Renal artery (contrast)AbdomenPelvisLegsOther
Ortho: which parts to be MRI scanned? - type out or click on selected

HeadNeckShoulderThoracic spineEntire spineHipsKneesAnklesFootWristElbowOther
When should we contact and arrange for a scan?*

Clinically urgent (next list)Clinically routine (currently within a week of first referral request)Arrange but defer appointmentDefer then arrange appointment at later date (ie place on recall list)Other
Indication/ clinical question?

Health screen (no or minimal symptoms)Chest symptoms ? causeBreathless ? causePalpitationselect from common referral reasons list belowAdd more info on referral reasons
Other reason(s) for test, click any that apply*

Investigation of angina? anomalous coronaryPost invasive angio, more data requiredInvestigation of AF or echo abnormalities ? CHDHypertensionCHD risk assessment (to estimate 10 year risk)Pre Cath work upPre op workupBreathless ? causeAssessment of aortic stenosisSuitability for TAVIHypertension? renal artery stenosis or coarctationChest nodule follow upEnlarged aorta investigate/followupHeart failure investigate causeValve issue routine follow up scanOther
Type reason for tests/ question to be addressed
The justifying Cardiologist/Radiologist will then assess best protocol to use.
key questions affecting scan

Certain questions must be included on the official request form to ensure safety. Please answer accurately. If answers are not known, select 'Not Known' so that schedulers can contact patient to find out. This can delay Justification and booking of the scan by 2-3 days.
Will there be IV Contrast required?*

YesNoNot sureOther
Contraindications - complete in all CTCA referrals*

No prior contrast reaction, asthma, diabetes, metformin or allergies, no Renal issues, can take betablockersOne or more issues that may affect contrast CT angiogramOther
CHECK1 for Cardiac (and some Chest CT) requests, your patient:*
CHECK2 for Cardiac (and some Chest CT) contrast requests, your patient:*

Contraindications - complete in all MRI referrals*

No prior gadolinium contrast reactionno Renal issuesNo Metal in eyeNo Metal clips in headOther
CHECK1 for Cardiac MRI requests, your patient:*

For Contrast MRIs*

	Yes	No	Not Known
Has the patient had IV contrast before?
Does the patient have any allergies (eg Iodine)?
Is the patient a Diabetic?
Is the patient taking Metformin?
Does the patient have renal disease?

For Cardiac CTs*

	Yes	No	Not Known
Dose the patient have a Cardiac Pacemaker /device?
Has the patient had prio heart surgery?
Has the patient had prior Coronary stent?
Are there any issues with taking Betablockers?

Contract? who will be paying for the scan(s)?*

NHSPP self fundPP PMIOther
PMI

Non using PMIBUPAAXA PPPCignaOther
We are sorry that at present NHS patients cannot currently be referred to VCL.

VCL can offer NHS contracts to selected CCGs/CCGs.

Please contact us to arrange.
additional information for test (other conditions, U&Es, address)

attached (phone/file/field completed)dictation attacheddictated letter to followcontact person will provide
My PAs Email address to notify and send copy of the completed form to this person
Dictate your referral or background info, including reason why required (useful when on the move, ward rounds etc)
Snap one image of signed request form or patient extra info via smartphone (fastest)
Or attach suitable image(s) from smart phone or PC

Browse Files

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If the patient is found to have coronary artery disease or other heart condition clearly requiring further specialist investigation or treatment, please indicate your preferred next steps:*

On receiving the report, a GP will arrange with a local providerWhere clinically urgent, vcl cardiology should arrange to avoid delay- refer all others back to referring GP to arrange with local providerVCL to refer all such cases direct to SASH consultantVCL to refer all such cases direct to RSCH consultantVCL to refer all such cases direct to FPH consultantVCL to refer all such cases direct to ASP consultantVCL to refer all such cases to any appropriate 'in house' VCL consultantOther
Initials of referring Doctor, or their representative confirming the above is accurate information and request has been made by a qualified person*
Type your name and role*
Who should be sent copy of results?

Patients registered GPReferring DrPatientsecretary specified aboveOther
Referring HCP or Secretary*

First NameLast Name
Practice or Surgery
Best Email to send confirmation email to and (where necessary) the completed request form to (eg your private secretary)
Leave empty if not required or the same as prior requests
Location
Office use
VCL Number
Staff Inits
Should be Empty:

	Yes	No	Not Known
Has the patient had IV contrast before?
Does the patient have any allergies (eg Iodine)?
Does the patient have Asthma?
Is the patient a Diabetic?
Is the patient taking Metformin?
Does the patient have renal disease?

E-Request form for Private Patients

Office use