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If you have a referral form from any clinician, please upload below and provide other details.
If you are self referring, please visit the
Self Refer Section
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Upload Referral Form (Self Pay)
Kindly upload the referral form from your clinician. Please note that we only accept referrals from UK based clinicians and it should not be more than 3 months old.
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
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Male
Other
Date of Birth
*
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Address - First Line
*
Postcode
*
Upload File 1
*
The letter needs to be signed by the referring clinician and must have the patient full name, date of birth, clinical indication, type of scan requested and the signature of the referring clinician.
Upload File 2
Upload File 3
Any special requests?
Terms and Conditions
*
I agree to the
terms and conditions
. I understand that the patient/client will be paying for the scan.
Name
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