Referrers Log In
Types of Patients
Patients - NHS Referral
GP Direct Access
Please select your MRI Scan Location
Penrith Association Football Club, CA11 8UA
Fairfield Independent Hospital, WA11 7RS
Louth County Hospital, LN11 0EU
Johnstone Community Hospital, Spalding, PE11 3DT
Parkway House, Northenden, Manchester, M22 4DB
Preston Grasshoppers Rugby Club, PR4 0AP
Sleaford Town Sports Association, NG34 9GH
Leeds County FA , Fleet Ln, Woodlesford, Leeds LS26 8NX
Please select body part(s) to be scanned (maximum of 4)
Ankle - Left
Ankle - Right
Elbow - Left
Elbow - Right
Foot - Left
Foot - Right
Hip - Left
Hip - Right
Knee - Left
Knee - Right
Shoulder - Left
Shoulder - Right
Soft Tissue (Muscle/Ligament Etc)
Sterno-Clavicular Joint Left
Sterno-Clavicular Joint Right
Temporomandibular Joint Left (TMJ Joints Are Scanned Together)
Temporomandibular Joint Right (TMJ Joints Are Scanned Together)
Upper Arm Left
Upper Arm Left
Upper Arm Right
Wrist - Left
Wrist - Right
Address (Including Postcode)
Date of Birth
The patient is referred by?
Name & Address (Including Postcode)
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:
Has the patient had any previous surgery, please provide details below:
Has the patient had any previous imaging, please provide details below:
⚫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?
⚫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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