PACS Request Form – Encapsulate

All NLAG, York and Leeds studies are already available to view through the Xero viewer. Need access? Request access to Xero.

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.

This form is for HUTH use only. For PACS requests at NLaG, please use the NLaG Radiology Image Request Form.

Name

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

Reference

What would you like to request?(Required)

Image Import

Image Export

CD (Hard Copy)

Anonymous / Trial Images

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)

Date of appointment or MDT(Required)

Images needed permanently?(Required)

Yes

Reason images are needed permanently?(Required)

If you selected 'Other', please provide details here(Required)

Reason for request(Required)

Other reason for request(Required)

Anonymous / Trial Details

Trial Name(Required)

Trial ID Number(Required)

R Number of Trial(Required)

Radiology Sponsor(Required)

Please specify identifier to be used for anonymising(Required)

ANON will be used if none given

Please specify if certain fields need to remain unchanged

Share file location for studies to be saved(Required)

Patient Details

Patient Name(Required)

Forename Surname

Patient Date of Birth(Required)

Patient ID Number (including prefix)(Required)

If no patient ID 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.

Details of each exam required, including study date(Required)

If you are requesting multiple exams, please state each study and the study date. The form will be returned if this is unclear.