• MRI Scan from £229 - Same day appointments.
  • Open MRI from £375 - Same day appointments.
  • Endoscopy from £900                                                             
  • Ultrasound from £49                                                                   
  • X-Ray from £55                                                                       

Diagnostic Imaging Referral Form

  1. Diagnostic Request Form* Please make a selection
  2. Patient Details

  3. Name* Please enter patient name
  4. Date of Birth (dd/mm/yyyy)* Please enter patients date of birth (02/06/1977).
  5. Address* Please enter patients address.
  6. Tel No.* Please enter patients telephone number.
  7. Insurance Company Please enter patients insurance company name.
  8. Insurance Policy and Authorisation number Please enter Policy number.
  9. Referring Clinician

  10. Registration Number/Professional Capacity * Please enter valid registration number.
  11. Name* Please enter Referring Clinician name.
  12. Tel No. Please enter telephone number.
  13. Fax No. Please enter fax number.
  14. Email* Please enter email address.
  15. Date Please enter date
  16. Please tick to confirm
    *

  17. Service Required* Please make your selection
  18. Body part to be scanned Please enter body part to be scanned
  19. Clinical Details* Please enter Clinical Details.
  20. Pregnancy Rules: In all women of reproductive capacity, the clinician should consider the possibility of an early pregnancy. For most examinations, the risk to the foetus is negligible during the first 28 days following commencement of the last period. However, examinations involving a high dose of the pelvis (i.e. Abdominal or Pelvic X-ray) should be confined to the first 10 days unless there are overriding clinical indications. To be completed if 28 day rule is exceeded.

    Upon arrival into the imaging department you will be asked to sign this referral to confirm your pregnancy status

  21. Exposure to Ionising Radiation Regulations: The Practitioner requesting the X-ray examination must be satisfied that it is necessary and that it will directly affect patient management. It must be ensured that the investigation has not already been carried out at this Centre or elsewhere. Any proposed deviation from the current Royal College of Radiologist’s guidelines must be discussed with a radiologist. Each request must be signed by a medical practitioner.

  22. Exposure Factors/Dose Please enter body part to be scanned
  23. 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.

Chartwell Diagnostic Imaging Centre is approved with all major insurance companies.