Upright MRI

Self Referral Form

Please complete the form below and send to us so that we can assess and then contact you to discuss and also arrange a suitable appointment time.


    MaleFemale

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

    Examination Requested


    mobilitylanguagesitehearing

    NHS GP

    It is a requirement that we communicate results to your NHS GP in order that they can make recommendations about your future care. By submitting this form 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

    Satety Information

    Have you had an MRI scan before?
    YesNo
    If yes, Where?
    Date
    Do you have a heart pacemaker?
    YesNo
    Have you had any surgery to your heart such as heart valves or stents?
    YesNo
    Have you had any operations to your head or brain?
    such as insertion of aneurysm clips...
    YesNo
    Do you have a reprogrammable ventricular shunt?
    YesNo
    Have you had any surgery to your eyes or ears - specifically insertion of cochlear/stapes implants?
    YesNo
    Do you wear a hearing aid?
    YesNo
    Have you had any surgery to any part of your body that might have involved metal clips, mechanical implants?
    YesNo
    Do you have a neurostimulator?
    YesNo
    Have you had an endoscopic procedure involving the swallowing of a transit camera?
    YesNo
    Have you any tattoos or eyeliner tattoos?
    YesNo
    Have you any skin patches e.g. hormone, nicotine etc?
    YesNo
    Have you ever had any metal fragments fly into your eyes?
    YesNo
    Have you had any gunshot or shrapnel injuries or any accidents where metal may have entered your body?
    YesNo
    Do you suffer from diabetes or epilepsy?
    YesNo
    For female patients: Is there any possibility that you are or may be pregnant?
    YesNo
    I understand that my images may be used in an anonymous form in medical research publications for the progression of research and education.