If you are self referring, please fill the below Scan Booking Request form.

If you have a referral letter from your GP/Consultant, please Upload Here.

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 TimeNo PreferenceMorning (Between 9am to 12pm)Afternoon (Between 12pm to 4pm)Evening (After 4pm)

Name *

Email *

Phone Number *

Secondary Phone Number (optional)

Gender *Select GenderFemaleMaleOther

Date of Birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Address - First Line *

Postcode *

Clinical Details

Type of Scan RequestedNot Sure - Need AdviceMRI ScanMRI Scan - CardiacMR AngiographyMR ArthrogramCT ScanCT Calcium ScoringCTCA - CT Coronary AngioogramCT 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.

Message

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