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Please Note: In order for AJCH to efficiently manage your referral, this form must be fully completed and along with all requested documentation. All referrals will be dealt with between the hours of 09:00 -14:00 Sun- Thurs.

Referring Physician Details
Patient Details
Male Female
Parent/Guardian Details
General Radiology – No Appointment Needed – Walk-Ins Welcome
Chest Skull Abdomen Extremity: Right or Left or Specific region:

Spine: Specify region

Other: Specify region
Renal Head Testicular Abdomen
Doppler: Specify region

Other: Specify
Upper GI (Stomach) Upper GI with Small Bowel Colon (Barium Enema) VCUG
Other
CT Scan of
MRI Scan of
MRA Scan of
Complete mri order questionnaire on page 3 for all mri studies.
Intravascular Contrast Screening Form

The Department may contact you for additional information to assist in scheduling the exams if answering yes to any of the following questions:

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Mri Order Questionnaire Form

The Department may contact you for additional information to assist in scheduling the exams if answering yes to any of the following questions:

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Submit

Al Jalila Children's Specialty Hospital

Al Jaddaf - Dubai United Arab Emirates

800 AJCH (8002524)
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