Private Referral

Please select your MRI Scan Location *

Please select body part(s) to be scanned (maximum of 4)

Patient Details:

First Name *

Middle Name

Surname

Address (Including Postcode)

Gender

Date of Birth

Enter Telephone

Enter Mobile

Enter Email *

Referring Clinician:

The patient is referred by?*

Name & Address (Including Postcode)

Enter Telephone

Enter Email

Enter GMC Number (if known)

Patient Clinical Information:

Presenting complaint & reason for an MRI scan?

Please provide as much relevant clinical information as possible to assist with the interpretation of the referral and images:

Previous Surgery
Has the patient had any previous surgery, please provide details below:

Previous Imaging
Has the patient had any previous imaging, please provide details below:

Additional Information
⚫Does the patient suffer from claustrophobia?
⚫Does the patient suffer from epilepsy?
⚫Has the patient had any operations on their brain?
⚫Has the patient had any operations on their spine?
⚫Has the patient had any operations in the last 6 weeks?
⚫Has the patient had any shrapnel type injuries involving metal?
⚫Does the patient wear a medicine patch e.g. nicotine, angina, contraception?
⚫Does the patient suffer from regular fits/blackouts?

Safety Questions
⚫Does the patient have a cardiac (heart) pacemaker?
⚫Does the patient have an aneurysm clip in their brain?
⚫Does the patient have a programmable hydrocephalus shunt?
⚫Does the patient have a cochlear implant?

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