Organisation*

Lead Contact*

Email*

Phone

Purchase Order / Reference

Name*

Date of Birth

Identifiers (NHS No. / Case ID)

Date / Time of Death

Purpose of Imaging*

Suspected mechanism / relevant history

Invasive autopsy planned?*
YesNoUnknown

Devices / foreign bodies suspected

Transport details (from / to)

Chain-of-custody start / end times

Identifiers verified?
YesNo

Secure transfer method required

Required turnaround*
24h48hASAPOther

3D reconstruction needed?
YesNo

Deliverables
PDF reportDICOMKey imagesOther

Primary contact

Out-of-hours contact

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