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Step 1 of 4 - Service Requirement

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what service are you looking for?

*Please select service required
Standard MRI*
HEAD & NECK*
BACK*
ABDOMINAL*
JOINTS*
Open MRI*
HEAD & NECK*
JOINTS*
WHICH LOCATION ARE YOU INTERESTED IN?*
Which location are you interested in?
* This service is not available at LEIGH-ON-SEA CLINIC, ESSEX
Which location are you interested in?
* This service is not available at HENDON CLINIC, LONDON
Are you the Patient or are you a Healthcare Professional referring a patient?*
** Important Notice : Follow-up Consultation: As a diagnostic imaging clinic, it is a requirement for us to be able to communicate results to a Healthcare Professional, already involved in your care, so that they may discuss the report and make recommendations about future care. Therefore, we cannot perform any diagnostic imaging scan if you cannot, or do not wish to provide the name and contact information of your chosen Healthcare Professional.
** Important Notice : At MRI Plus, we would always recommend that you obtain a referral from a Clinical Professional for any diagnostic imaging service. Unfortunately, we are unable to accept self-referrals for any diagnostic imaging that uses x-rays. X-rays produce ionising radiation, which is a form of radiation that has the potential to harm living tissue. The risk increases with each exposure over a lifetime, so x-rays are usually limited to reduce this risk. If you have a referral form written by a qualified healthcare professional, you can complete our online form and send a copy of your referral form via email prior to booking your appointment.
What type of clinician do you wish to receive your results and speak to you about ongoing care/treatment?
IF YOU DO NOT KNOW THE NAME OF YOUR DOCTOR, please state the NAME OF THE GP SURGERY instead.
Name of Healthcare Professional
Healthcare Professionals Address*
Please state any symptoms you have been experiencing, when these symptoms started, any tests or scans you may have had and any medical advice you may have received from your GP or Healthcare Professional. This will help us to identify what we might be scanning for and enable us to provide the best possible images for your GP/clinician to provide ongoing care and/or treatment.

REFERRING A PATIENT

Referring Clinician Details

Referrers Name*
Referrers Address*
This will help us to identify what we might be scanning for.

PATIENT DETAILS

Patient Name*
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Patients Date of Birth*
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Patients Address*
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How are you funding your scan?*
Patient Funding*
Are you biologically Male or Female?*
Is there any possibility that you are pregnant?**
Are you currently breastfeeding?*
Do you have breast implants that contain a valve?**
Do you have a cardiac pacemaker?**
Do you use, or have fitted, any devices or neuro stimulators?*
Have you ever had any heart, lung or chest surgery?**
Have you had any operations to your head or brain or have a shunt to drain fluid?**
Have you ever had a foreign metal fragment enter your eyes?**
Do you have any devices, implants, artificial limbs, joints, metal plates, pins or screws in your body?*
Do you suffer from fainting, blackouts, diabetes, asthma or any similar condition?**
Have you any operations in the last 6 weeks?*
Do you have any removable dental work, hearing aids or medicine patches on your skin?*
DD slash MM slash YYYY
Preferred Time For Scan*
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Consent*
Disclaimer: Prior to undergoing any MRI Imaging procedure, all patients are advised they should consult with a GP/Healthcare Professional, involved in their ongoing care, regarding their health concerns. As a self-referring patient, you recognise that the area(s) to be scanned have been identified by myself and that MRI Plus Clinics shall only scan and report on the findings of the specific area(s) mentioned. MRI Plus Clinics will not accept any liability should the area scanned subsequently be defined as incorrect or inappropriate to any clinical symptoms or diagnosis at this time or in the future.

Cancellation policy: If, for any reason, you are unable to attend your appointment, please contact the centre at least 48 hours before your scheduled appointment time to cancel or reschedule your appointment.
Cancellation of a pre-paid appointment at least 48 hours before the scheduled appointment can be rescheduled or refunded at no cost.
If the appointment is booked within 48 hours of the scheduled appointment time, the service cost will be non-refundable and cannot be rescheduled.
If you are unable to attend and do not cancel or reschedule your appointment, please note that a ‘Missed Appointment’, ‘No Show’ or ‘Late Cancellation’ will be charged at the full service cost due to the time and resources used. The definition of ‘Missed Appointment’, ‘No Show’ or ‘Late Cancellation’ would be missing an appointment, not being on time for an appointment or failing to cancel the appointment 48 hours before the scheduled time.
If you are unable to complete the scan for any reason you will not be refunded due to the time and resources used.
If you are unable to attend due to COVID-19, we would ask you to follow the Government guidelines on self-isolating and contact us to rearrange your appointment when it is safe to do so. We may request evidence of this, so please be prepared to provide this.


MRI Plus Clinics reserve the right to refuse any referral.
Consent*
By submitting this form, you confirm that you have a referral letter written by a qualified healthcare professional, and that you will send a copy of your referral form via email prior to booking your appointment.

MRI Plus Clinics reserve the right to refuse any referral.
Consent
Consent*
1. Scans will only be offered to all patients aged 18 and above, or 16 and above with parent/guardian consent and presence.
2. Magnetic Resonance Imaging (MRI) is extremely safe and does not involve any radiation exposure. However, you are required to complete a safety questionnaire at the time of booking. Please note that this may exclude you from proceeding with the scan or delay the scan, depending on the information you provide.
3. You will be required to complete a Self-referral form, clearly providing the reasons for requesting an MRI scan, whether it is for a medical complaint or reassurance, we would request that you provide as much information as possible.
4. If a comparison scan is required, please ensure you provide us with your previous MRI report and MRI images or details of where this can be obtained. Failure to do so may result in a delay on the completion of your report. Please note that we are unable to offer a comparative report on any other type of diagnostic imaging such a CT Scan, X-Ray or Ultrasound.
5. You must be registered with a GP, or other responsible medical practitioner (e.g. for overseas patients), to whom we will send a copy of your report.
6. As a diagnostic imaging clinic, it is a requirement for us to be able to communicate results to a doctor, already involved in your care, so that they may discuss the report and make recommendations about future care. Therefore, we cannot perform any diagnostic imaging scan if you cannot, or do not wish to provide the name and contact information of your registered doctor.
7. Scans will only be performed on the areas which we routinely scan. The Self-referral form will be assessed and protocolled, and you will be advised if we are unable to proceed with the requested examination.
8. Self-referrals will not be accepted for contrast enhanced scans. If contrast is required, a referral form must be obtained from your registered GP or a specialist.
9. Self-referrals will not be accepted if you are engaged in professional sports or for anything connected with a professional sports club, of which you are a member.
10. Self-referrals will not be accepted for monitoring of known malignant disease.
11. You should be aware that MRI scans may identify unexpected abnormalities, which may or may not require further investigation. In this instance, the findings will be highlighted on the report and any recommendations from the reporting radiologist must be followed up with your GP or specialist.
12. You should understand that the imaging report may contain medical terminology that may be confusing or possibly upsetting, but neither the reporting radiologist or any staff within the MRI clinic are able to discuss the findings of the scan directly with any patient. All enquiries and/or recommendations must be explored with your GP or specialist.
13. Your GP will have the ability to contact the reporting radiologist for further information regarding your report.
14. You are welcome to bring a friend or relative with you, who may accompany you during your scan, subject to safety checks. Please note that you cannot be accompanied by any persons under the age of 16.
15. You must provide all your contact details, so that we may contact you, and you will be required to confirm your appointment 48 hours prior to your appointment.
16. After your scan, you will only receive a CD containing your magnetic resonance images if this is included in your package or you have paid the additional charge. Any additional copies of the CD will be chargeable at the standard rate.
17. After your scan, the radiology report will be sent to your GP or Specialist within the timescale stated on your selected MRI package. We are unable to release the radiology report directly to any patient. You will need to be arrange a follow-up appointment with your GP or Specialist to obtain a copy of your report and discuss your results.
18. Neither the NHS nor any private medical insurance providers will fund the costs of a Self-referred MRI scan. As such, all Self-referrals are accepted on a Self-pay basis only.
19. You accept that you are solely responsible for choosing the area(s) you wish to have scanned and that you are not replying on any input, clinical or otherwise, from the MRI Plus clinic.
20. If you are unable to attend your appointment, you must reschedule or cancel 48 hours before the scheduled appointment. Any appointments cancelled within 48 hours of the scheduled time will be non-refundable and the appointment cannot be rescheduled. If the appointment is booked within 48 hours of the scheduled appointment time, the service cost will be non-refundable and the appointment cannot be rescheduled.
21. MRI Plus Clinics reserve the right to refuse your Self-referral form.
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Consent*
Important Notice: We have partnered with European Scanning to offer this service.
Please note that by completing this form, you understand that we will be passing on your contact details to our chosen partners, the European Scanning Centre in Harley Street, who will be in contact to arrange your appointment.

Examination Requested

MRI

  • Head
  • Brain
  • Whole Spine
  • Lumbar Spine
  • Shoulder
  • Pelvis & Hips
  • Knee

Other Services

  • X-Ray
  • Ultrasound
  • Private GP
  • DEXA

About MRI Plus

  • MRI Plus Difference
  • For Health Professionals
  • For Patients

Frequently Asked Questions

  • How much does an MRI cost?
  • How do I book my MRI?
  • What happens in my MRI appointment?
  • What is an Open MRI scan?

CONTACT US

W: Send WhatsApp

P: 0800 038 5772

E: info@mriplus.co.uk

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