Self Referral
Please select your MRI Scan Location
*
<----Select Site---->
Boston Enterprise Centre
Johnsone Community Hospital, Spalding, PE11 3DT
Louth County Hospital, LN11 0EU
Manchester Rugby Club
Modality Treatment Centre, Birmingham, B16 8PE
Nottingham Rugby Club, Nottingham, NG2 5AA
Penrith Association Football Club, CA11 8UA
Practice Plus Group Hospital (Barlborough)
Practice Plus Group Hospital (Bristol)
Preston Grasshoppers Rugby Club, PR4 0AP
Sleaford Town Sports Association, NG34 9GH
West Riding County Football Association, LS26 8NX
Select a Site
Please select body part(s) to be scanned (maximum of 4)
Adrenals
Anal (Pelvis) Fistula
Ankle left
Ankle right
Brachial Plexus
Brain
Elbow left
Elbow right
Femur Left
Femur Right
Foot left
Foot right
Groin Left
Groin Right
Hand left
Hand right
Hip left
Hip right
Hips Both
IAMs
Knee left
Knee right
Lower Legs (Both)
Mastoids
MRA COW(non contrast)
MRA Neck(non contrast)
MRCP
MRV Cerebral Veins
Orbits
Pelvis - MSK
Pelvis-Gynae
Pituitary- non contrast
Shoulder left
Shoulder right
SIJs
Sinuses
Spine cervical
Spine lumbar
Spine thoracic
Spine whole
Whole body scan
Wrist left
Wrist right
Patient Details:
First Name
*
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Surname
Blank Field Not Acceptable
Title
*
<----Select Title---->
None
Dr.
Mr.
Ms.
Mrs.
Miss
Sister
NA
Prof.
Select Title
Address
*
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Town
*
Postcode
*
Gender
*
Male
Female
Unknown
Date of Birth
*
Enter Mobile
*
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Enter Telephone
Enter Email
Enter A Valid Email ID
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:
Previous Surgery
Please provide details of any previous surgery below:
Previous Imaging
Please provide details of any previous imaging below:
Please complete this questionnaire prior to submitting your request for an appointment.
A member of our clinical team may contact you prior to booking to clarify any potential MRI safety issues.
Do you have a cardiac pacemaker or intra-cardiac device?
YES
NO
Have you ever had surgery to your brain, heart, eyes, or ears?
YES
NO
Have you had any surgery in the last 6 weeks?
YES
NO
Do you have any aneurysm clips, surgical implants, internal devices, stents or shunts?
YES
NO
Have you ever, in your lifetime, had an accident where metal may have entered your eyes or your skin?
YES
NO
Do you wear a medicated skin patch or monitoring device?
YES
NO
Are you or might you be pregnant?
YES
NO
Do you weigh more than 21 stones / 133kg?
YES
NO
Do you require any form of additional assistance during your appointment?
YES
NO