To make an appointment, call 0203 312 7605

Referral Form

We welcome referrals from any UK registered doctor by faxing a signed letter on headed paper to
0203 312 7607 which includes the patient's full contact details, diagnosis, scan required and information needed from the study. 

Please ensure you advise us where you'd like the report and images to be returned to. 

If you would like us to send you a referral pad, please email reception@mrtherapycentre.com or telephone 0203 312 7605.


    
Patient Surname: First Name:
Patient Address: DOB:
  Male/Female
  Office/Home No.:
  Mobile No.:
  Referring Hospital:
   
 

Referring Consultant:

  

PP/Other                               Inpatient / Outpatient:

Walking / Chair / Trolley

Area(s) to be scanned:
Clinical Details:
(Previous surgery)
Information Required:
Previous Scans / X-Rays:
Has the patient pacemaker / prosthesis / implant?:
   
 

 E-mail:

 Report via:        Tel / Fax / Email / Post
Consultant: Address Details:
    Tel:
Fax: Date:

                                                                     

Contact
Name
Email
Phone
Message
Security Code:
 

© 2011 MR Therapy Centre, Clarence Wing Basement, St Mary's Hospital, Praed Street, London, W2 1NY

E-mail: reception@mrtherapycentre.com       Phone: +44 (0) 203 312 7605       Opening Hours: Monday to Friday: 8.30am to 5.30pm | Wednesdays: 8.30am to 8pm

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