Patient Referral

This referral form is for use by healthcare professionals only. Please fill in as many fields as possible making sure you have filled in the mandatory fields highlighted with an *. On receipt of your referral form, our reception staff will contact your patient to arrange a suitable appointment date.

Patient details

Title*

First Name*

Last Name*

Email*

Preferred Contact Number*

Date of Birth*

Gender*

Male

Female

Address*

Town

County

Postcode

Mobility*

Mobile

Non-mobile

Funding

Payment method*

Self-pay

Insured

NHS

Embassy

Insurance Company

Policy number

Pre-authorization no.

Policy excess

Region to be scanned

Urgency

Urgent

Non-urgent

Flexion & Extension

Yes

Relevant clinical details – What information are you seeking from this examination?

Previous relevant surgery

Safety check (as recommended by the MHRA, the referring practitioner is required to assess patient safety for MRI scans)

Cardiac pacemakers, spinal cord stimulators, cerebral aneurysm clips, metallic heart valves, cochlear implants are contra-indications for MRI

Possibility of pregnancy?

Yes

Referring practitioner

Title*

Name*

Email Address*

Telephone Number*

Fax

Practice / Hospital*

Address*

Town

County

Postcode

How would you like to receive the report?

Post

Fax

Report to be given to patient?

Yes

IV Contrast (Iodine or Gadolinium)

To minimise the risk of contrast nephrotoxicity it is the responsibility of the referring clinician to provide an indication of renal status or to ensure that a recent eGFR and a serum creatinine level are available

Serum Creatinine

eGFR

Date Measured

Refer to *

London Centre

Manchester Centre

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