Referrer:   Patient details:
     
Title.   Surname.
 
Referrer Name.   Forename.
 
    DOB.
  Day Month Year
Referrers Address.   Patients Address.
 
Referral ID Number:    
   
Contact Details: e-mail & telephone   Telephone.
 
Clinical Indication: Please include relevant previous diagnostic information or medical history.
Preferred radiologist:
Examination requested: XRay
CT
MRI
US
 

Please Note:

Patients with certain surgically implanted items may not be suitable for MR imaging.
Patients with significantly reduced renal function may not be suitable for CT or MR contrast agents.

 

Date:

Click Here to Pick the date.
We have asked the patient to call 9 Harley Street for an appointment.
Please contact the patient with an appointment.
This imaging needs to be completed today.
This imaging needs to be completed within three days.

We recognise doctors work in teams and that many of our referring doctors prefer a specific radiologist to provide their reports. We are happy for any radiologist who is an NHS consultant, or who has been an NHS consultant, to report your images. Please enter your preferred radiologist on the request. Most radiologists are already set up at 9 Harley Street, and by using our web server they can report from a remote site. If you do not enter a name we will select the most appropriate radiologist from our list.

We provide all images on a CD which can be read on your computer with no additional software. Unlike many systems, you can download and save images to your records.

You can also access images online via our web server. Please contact us if you would like this facility and we will be happy to provide our terms of use and to arrange this for you at no charge.