Book a full-body* preventative cancer MRI screening today!
close icon
LONDON: 020 7079 2100
ESSEX: 01245 801234
About Us

Cardiology Request Form

This form is for medical professionals only.

Here you will be able to refer your patients for a wide range of cardiovascular diagnostic tests.

Please complete this online form and a member of the Phoenix Diagnostics team will be in touch.

 

 

    Select A Location
    Important Information
    Do you need to request an urgent report?*
    If you ticked yes, please state the preferred date and time you would need the report by:
    Patient Details
    Examination / Procedure
    Examination Requested
    Referring Clinicians Details
    Referrers Declaration
    • The correct details have been provided.
    • I have discussed the examination including any intervention.
    • I have taken into account possibility of pregnancy.
    • I have given sufficient clinical information for the requested to be justified according to IR (ME)R 2000.
    • There are no known contra-indications to performing the requested examination.
    • I will ensure the examination results are recorded in the patient notes.
    • The Ionising Radiation (Medical Exposure) Regulations 2000 require you to complete all this information accurately.
    • I confirm this is my approved signature
    • By sending this e-mail, I am signing this referral electronically. I agree that my electronic signature is the legal equivalent of my manual signature on this referral form and has the same validity. I consent to be legally bound by this Agreement's terms and conditions.

    we will never share your details and will only send you information about our healthcare services

    CALL US NOW
    LONDON: 020 7079 2100
    ESSEX: 01245 801234