Self-Referral MRI Form Page

Imaging Self-referral Form (18+ only)

I am aware of the £100 non-refundable GP triage fee (if not required, it will go towards your treatment cost)

I have read and agree to the Terms & Conditions and Privacy Policy

Your Personal Details

Title*

First Name*

Last Name*

Date of Birth*

Gender*
MaleFemaleTransgenderPrefer not to say

Do you play paid professional sports?*
NoYes

Address Line 1*

Address Line 2

Town / City*

County

Postcode*

Telephone*

Email*

GP Name/Surgery*

GP Address*

Referral

Referring YourselfBeing Referred

Examination

Select the examination required*
Please selectBrainCervical spineShoulderElbowsHandsThoracic spineLumbar spineprostateKneesFeet anklesHipsLower legsWrist

MRI Scan - Safety Information

Cardiac pacemaker / defibrillator*
Please selectNoYes

Head / heart / eyes / ears operations*
Please selectNoYes

Blood vessel procedures*
Please selectNoYes

Implants or medical devices*
Please selectNoYes

Penetrating eye injury (metal)*
Please selectNoYes

Shrapnel injury*
Please selectNoYes

Recent surgery (past 6 weeks)*
Please selectNoYes

History of cancer or long-term condition*
Please selectNoYes

Pregnant*
Please selectNoYes

MRI Scan - Further Information

Why do you want this scan?*

What symptoms are you experiencing?*

How long have you had symptoms?*

Select Body Area 1*
—Please choose an option—MRI BrainMRI Spine lumbar and sacral (Lower)MRI Spine thoracic (Middle)MRI Spine cervical (Upper)MRI Knee LtMRI Knee RtMRI Ankle LtMRI Ankle RtMRI Elbow LtMRI Elbow RtMRI Femur LtMRI Femur RtMRI Foot LtMRI Foot RtMRI Forearm LtMRI Forearm RtMRI Groin LeftMRI Groin RightMRI Hand LtMRI Hand RtMRI Hip LtMRI Hip RtMRI Lower leg LtMRI Lower leg RtMRI Musculoskeletal Pelvis (Pelvic Bone / Hip Joints)MRI Sacroiliac JointsMRI Shoulder LtMRI Shoulder RtMRI Upper arm LtMRI Upper arm RtMRI Wrist LtMRI Wrist RtOther

How did you hear about us?

GoogleFriend/Family memberDoctorSocial MediaOther

Once you submit the form we will contact you to discuss your scan, arrange an appointment and make payment.