Once we have your completed form, we will contact your patient to arrange a convenient time for them, and send you the report within 48 hours of appointment.

To be sent a supply of referral forms please contact our bookings team on 0800 222 9048.

* - required field

1. Referring Clinicians










EmailPostFax

YesNo

2. Patient details






MaleFemale




Self payInsuredThird partyNHS

3. Procedure details

RoutineUrgent

Open MRIMRICTInterventionalUltrasoundX-rayBone DensitometryMammogram

Relevant clinical details


MRI details



MRI Safety questions

YesNo

YesNo

Relevant clinical details


Relevant clinical details


CT safety questions

CT contrast investigation: In line with the Royal College of Radiologists guidelines a recent (in the last 3 months) serum creatine level or eGRF must be available level prior to imaging.



Relevant clinical details


Relevant clinical details


Relevant clinical details


Relevant clinical details


Relevant clinical details





MorningAfternoon
4. Relevant clinical details

5. Preferred consultant


6. Terms of service

What our clients have to say…

"The service I received was more than exceptional, my needs were accommodated and my fear of claustrophobia was managed by using the fantastic Open MRI machine. I was treated with dignity at all times"

"Thank you to all staff members who assisted me during my visit, my experience was pleasant and I would happily visit Harley Street Medical Centre again"

"The whole patient journey was exceptional, I felt extremely comfortable and at ease during my scan"

"The staff were extremely patient and empathetic during my MRI scan, the thoughtfulness was greatly appreciated and admired"