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Home > Imaging Request Form

Imaging Request Form

This form is for medical professionals only.

Here you will be able to refer your patients for an MRI, CT, USS, X-ray and DEXA.

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

Please note* a normal turnaround time for reports is 24 hours, however, urgent reports can be requested and accommodated depending on availability of a radiologist.

Select A Location

London

Essex

Important Information

Do you need to request an urgent report?*

Yes

If you ticked yes, please state the preferred date and time you would need the report by:

Preferred Date

Preferred Time

Patient Details

Title*

First Name*

Last Name*

Date of Birth*

Email*

Address Line 1*

Address Line 2

City*

County

Postcode*

Phone Number*

Examination / Procedure

Preferred Radiologist

Scan Required:

MRI

X-Ray

Dexa

Ultrasound

Examination Area*

Clinical Indication

For female patients

LMP Date

Referring Clinicians Details

Title*

First Name*

Last Name*

GMC Number (if applicable)

Phone Number*

Email*

Address Line 1*

Address Line 2

City*

County

Postcode*

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 2017.
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.

Signed (name)*

Date*

Please leave this field empty.