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If you are self referring, please fill the below Scan Booking Request form.
If you have a referral letter from your GP/Consultant, please
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Scan Booking Request (Self Pay)
An independent GMC registered GP will assess the form and will call within a few business hours to discuss and recommend an appropriate scan
Preferred Appointment Date
Preferred Appointment Time
No Preference
Morning (Between 9am to 12pm)
Afternoon (Between 12pm to 4pm)
Evening (After 4pm)
Name
*
Email
*
Phone Number
*
Secondary Phone Number (optional)
Gender
*
Select Gender
Female
Male
Other
Date of Birth
*
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Address - First Line
*
Postcode
*
Clinical Details
Type of Scan Requested
Not Sure - Need Advice
MRI Scan
MRI Scan - Cardiac
MR Angiography
MR Arthrogram
CT Scan
CT Calcium Scoring
CTCA - CT Coronary Angioogram
CT Virtual Colonoscopy
Body Parts to be Examined
*
Abdomen (Adrenal, Kidneys, Liver, Pancreas)
Angiogram (Arteries and Veins)
Ankle - Left
Ankle - Right
Brain (Head)
Breasts - Both
Calf (Lower Leg) - Left
Calf (Lower Leg) - Right
Cardiac (Heart)
Chest (Lungs)
Elbow - Left
Elbow - Right
Foot - Left
Foot - Right
Hip - Left
Hip - Right
Inner Ears (IAMS) - Both
Knee - Left
Knee - Right
Pelvic
Pituitary Gland
Prostate
Sacroiliac Joints
Shoulder - Left
Shoulder - Right
Sinuses (Paranasal)
Small Bowel
Spine - Cervical (Neck)
Spine - Lumbar (Lower Back)
Spine - Thoracic (Middle Back)
TMJ Joints (Temporomandibular)
Testicles
Thigh - Left
Thigh - Right
Upper Arm - Left
Upper Arm - Right
Wrist - Left
Wrist - Right
Other
Symptoms (Provide details for each body part to be examined. For how long you had the symptoms?)
*
Have you had other tests or scans for these symptoms? When?
Have you shown it to your GP or Consultant? What are their comments?
Any related surgeries or treatments in the past?
Any known medical conditions?
Any special requests?
Important - Please mark if the patient has any of the below conditions:
Epilepsy?
Clips or foreign bodies in Brain / Spine
Pregnancy or Breast-feeding
Surgeries in last 2 months
Shrapnel or metal objects
Medicinal patch
Any history of regular fits/blackouts
Metal fragments in Eyes
Cardiac Pacemaker
Hydrocephalus Shunt
Renal / Kidney impairment
Cochlear implant
Claustrophobia
Disabled / On Wheelchair
Terms and Conditions
*
I agree to the
terms and conditions
. I understand this request will be assessed by an independent GMC registered clinician in the UK. The clinician may approve the request, deny the request or may suggest another diagnostic or screening procedure.
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