Self Referral Form

Your details

All information is treated in strict confidentiality and will only be shared with third parties who are involved in your care.

Examination requested

Safety details


It is a requirement that we communicate results to your NHS GP in order that they can make recommendations about your future care. By signing below you acknowledge and accept that:

  • A copy of your report will be sent to your GP
  • Neither the radiographer who has conducted the scan/form or the radiologist reporting it is able to discuss the findings of the scan with you; and
  • You have read and understood the Patient Information which you signed at the time of booking your scan.

Insured Patients

We are approved by all the major private insurance providers for MRI.

44 Newman Street, London W1T 1QD

020 7637

United Open MRI Ltd Registered in England and Wales Number:
4376558 Registered office 40 - 44 Newman Street, London W1T 1QD