Book MRI Scan - Phoenix Hospital Group

I am aware of the £50 non-refundable GP triage fee

Your Personal Details

Title*

First Name*

Last Name*

Date of Birth*

Gender*

Do you play paid professional sports?*

Address Line 1*

Address Line 2

Town / City*

County

Postcode*

Telephone*

Email*

Are you*

Referring YourselfBeing Referred

Select the examination required*

Do you have or have you ever had a cardiac pacemaker or internal defibrillator fitted to your heart?*

Have you ever had any operations or procedures carried out on your head, heart, eyes or ears?*

Have you had any operations or procedures carried out on any blood vessels in your body, such as aneurysm or vascular clips?*

Do you have any implants in, or medical devices attached to your body?*

Have you ever had a penetrating injury to your eyes involving metal?*

Have you ever suffered a shrapnel injury (bomb blast or gunshot)?*

Have you had any surgery or procedures carried out in the past 6 weeks?*

Do you have a history of cancer or a long term medical condition related to the area to be scanned?*

Are you pregnant?*

Please provide as much information as you can as to why you would like this scan.

Why do you want this scan?* What symptoms are you experiencing?* How long have you had symptoms?* Select Body Area 1*

Once you submit the form we will contact you to discuss your scan, arrange an appointment and make payment.