Fax Back Form to 01432 364015

 

Or post to:

Department of Radiology

 

County Hospital

 

Hereford

 

HR1 2ER

Tel:

01432 364454 (direct dial private patient line)

 

Hereford Radiology Group: Private MRI Request

Appointment date and time

 

Hereford Unit Number (if known)

Area to be scanned

 

 

 

  • Pacemaker/cochlear implant-Scan not possible.
  • Intracranial clips/shunt/cardiac valve- contact department
  • Metal fragments in eyes-Orbital x-rays may be required
  • Pregnant-Contact department

 

Clinical Details/Suspected diagnosis*

 

 

 

 

 

 

Patients wt:

Surname*

 

Forename*

 

DOB*

SEX: M / F

Address*

 

 

 

Post code*:

Phone number*

Home:

Work

Mobile:

Insured

Self-pay

 

Medico-legal

Cat II

 

 

Referrers contact details (or practice stamp)

Address*:

 

 

 

 

 

 

 

Phone number*:

 

Fax number (will be used to issue report)*:

 

 

Name of Referrer*

 

 

Referrer Signature*

Date*:

 

Office use: Justified by:

* Denotes mandatory information.

 

 

 

(return to home page)