MRI Questionnaire

MRI Scan Questionnaire

Please complete this MRI questionnaire before booking your private MRI scan.

This form is for non-urgent MRI scan requests only. If you have severe symptoms, major trauma, fever, or feel acutely unwell, please seek medical advice urgently.

Patient details

First name * Last name * Date of birth * Gender *Email * Phone number *

MRI scan details

Body part *Please describe your symptoms * How long have you had these symptoms? *Was there an injury? *Have you had previous surgery to this area? *

MRI safety questions

Are you pregnant or could you be pregnant? *Do you have a pacemaker or implanted cardiac device? *Do you have any metal implant, surgical clip, or implanted device? *Are you severely claustrophobic? *Approximate weight in kg *

Declaration

I confirm that the information I have provided is accurate.

I understand that my scan request may still be reviewed before the appointment is confirmed.

I consent to being contacted about this scan request.