MRI Referrals - Go2imaging

Please use this form if you would like our assistance with referring a patient for an MRI scan (or DEXA scan) to your local InHealth Centre. We will oversee the whole process, including arranging for the optimum type of scan (sequences and views), and a superior quality report from one of our preferred radiologists.
Step 1: Please complete the patient details and clinical detail forms to follow.
Step 2: To submit the form, please complete the payment using the online portal, either use your own credit / debit card (and arrange for the patient to reimburse you) or have the patient complete this step.
Steps 3 & 4: Your patient will be contacted by InHealth to arrange a time for their scan. You (the referrer) will receive the imaging report on email, usually within one to three days following the patient receiving their scan.

Patient Details

Title *

Address *

Name *

First

Last

Postcode *

Date of Birth *

Email *

Telephone *

Please use this form if you would like our assistance with referring a patient for an MRI scan (or DEXA scan) to your local InHealth Centre. We will oversee the whole process, including arranging for the optimum type of scan (sequences and views), and a superior quality report from one of our preferred radiologists.
Step 1: Please complete the patient details and clinical detail forms to follow. (completed)
Step 2: To submit the form, please complete the payment using the online portal, either use your own credit / debit card (and arrange for the patient to reimburse you) or have the patient complete this step.
Steps 3 & 4: Your patient will be contacted by InHealth to arrange a time for their scan. You (the referrer) will receive the imaging report on email, usually within one to three days following the patient receiving their scan.

Relevant Clinical Details

Regions to be scanned: *

Clinical reasons for scan: *

STANDARD (SUPINE) MRI *

MRI 1 Part (Nation Wide, UK) (£325)
MRI 2 Part (£500)
MRI 3 Part (£700)
MRI 4 Part (£900)
MRI Contrast (additional £125)
MRI Arthrogram (with X - ray I ultrasound guided Gadolinium Contrast) (£750)

OPEN MRI 0.6 T (For Claustrophobic Patients)

Open MRI 1 Part (London, Croydon, Birmingham, Leeds Open MRI 1 Part (London, Croydon, Birmingham, Leeds (£500)

UPRIGHT MRI 0.6 T (Weight Bearing Scans)

Upright MRI 1 Part Scanner (London, Birmingham, Leeds) (£850)

Additional Options for Open or Upright Scans

1 Additional Area (£300)
2 Additional Areas (e.g. whole spine: cervical, thoracic, lumbar) (£550)

Total Amount

£ 0.00

Is comparison required? *

Yes
No

Please use this form if you would like our assistance with referring a patient for an MRI scan (or DEXA scan) to your local InHealth Centre. We will oversee the whole process, including arranging for the optimum type of scan (sequences and views), and a superior quality report from one of our preferred radiologists.
Step 1: Please complete the patient details and clinical detail forms to follow. (completed)
Step 2: To submit the form, please complete the payment using the online portal, either use your own credit / debit card (and arrange for the patient to reimburse you) or have the patient complete this step. (completed)
Steps 3 & 4: Your patient will be contacted by InHealth to arrange a time for their scan. You (the referrer) will receive the imaging report on email, usually within one to three days following the patient receiving their scan.

Referring Clinician

Title

Name *

First

Last

Speciality / Profession *

Other Speciality / Profession

I confirm that i have patient's consent to provide their personal information with this referral

Professional registration number

Signature *

By typing your name above. this serves as your signature.

Hospital / Practice

Referral Date

Email Address *

Address *

Postcode

Telephone

Mobile Number *

Please use this form if you would like our assistance with referring a patient for an MRI scan (or DEXA scan) to your local InHealth Centre. We will oversee the whole process, including arranging for the optimum type of scan (sequences and views), and a superior quality report from one of our preferred radiologists.
Step 1: Please complete the patient details and clinical detail forms to follow. (completed)
Step 2: To submit the form, please complete the payment using the online portal, either use your own credit / debit card (and arrange for the patient to reimburse you) or have the patient complete this step. (completed)
Steps 3 & 4: Your patient will be contacted by InHealth to arrange a time for their scan. You (the referrer) will receive the imaging report on email, usually within one to three days following the patient receiving their scan.

Payment

Title

Name *

First

Last

Specialty / Profession

Other Specialty / Profession

Professional Registration Number

Email Address *

Address

Postal Code

Telephone

Do you want the report sent to another Clinician?

Signature

Referral Date

Total Amount to be Paid

£ 0.00

Credit Card *

Card

Name on Card

NB: Please instruct your patient NOT to make any direct payments to the InHealth centre, we will settle the cost of your patient's scan with InHealth.