Radiology Requestor Registration

Ultrasound requestor application

APPLICANTS

Please provide all of the details required in the form below. Once completed, a copy will be emailed to your Clinical Supervisor for approval.

Note: if you are registering as an MRI requestor, please select the New MRI Registration form from the menu above.

First name:

Please complete

Last name:

Please complete

Email Address:

Please complete with a valid Email Address.

Job Role

Please complete

Date Ultrasound Training Completed:

Please complete

Professional registration No:

Please complete

Local Plan(s):

Please select one Local Plan

NB: you MUST have a local plan. If you do not have one please check with your clinical supervisor.

if you work to more than one local plan, in different wards that you work for example, please select all that you work to.

Clinical supervisor - name:

Please complete

Clinical supervisor - role:

Please complete

Clinical supervisor - Email:

Please complete with a valid NHS Email Address

Range of investigations / scope of practice

Examination area / type
UltraSound:

Are you a FULLY INDEPENDENT PRACTITIONER?

I diagnose and treat patients in clinical practice, but a consultant is ultimately responsible for my patients.

Please confirm

OR

I work as a fully independent practitioner with my own patient list and take complete responsibility for my own patients without consultant oversight.

Please confirm

By submitting this you are confirming that:

You have read document CG52 (Non-medical requestor policy)
You understand that it is a legal requirement for non-medical requestors to have IRMER training prior to requesting radiological procedures.
You have completed all of the IRMER modalities listed below and have retained a record of completion which can be provided as evidence if requested.

(Please note you do NOT need to submit copies of your certificates, but you must retain copies of your training to be produced as evidence when required).