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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

    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


    Scan Required:



    Referring Clinicians Details












    How would you like to receive the report:
    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.


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