Referrer Booking form

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


Region to be scanned

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

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

Referring practitioner

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