Patient Self Referral Form

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With significant demands on the healthcare providers and the NHS, patient are finding it increasingly difficult to see a healthcare professional as well as accessing vital diagnostic services. As a result, patients are now seeking alternative sources.

When this involves an MRI scan, the Advanced Diagnostics department in St Josephs Hospital can now offer a self-referral pathway for imaging for patients that meet the specified criteria.

The following criteria will need to be met in order for a self-referral scan to be performed:

A person over 18 years of age.
A fully completed questionnaire must be provided.
The scan must not be to monitor the progress of malignancy.
The anatomical area to be scanned must be one from the accepted list.
The patient must provide details of a responsible clinician (GMC or HCPC registered) for the results to go back to for discussion.

About the Patient

Full Name *

Full Address *

Email Address *

Date of Birth *

Contact Telephone *

Gender *

About the Scan

What area of the body is the MRI required for? *

Side *

What symptoms do you have? (Please describe in detail) *

Have you had this problem previously? *

When did your symptoms start? *

Is there an additional area you wish to be scanned?

Responsible Clinician Details

Will your results be going back to your GP? *

GP Name *

GP Address *

GP Contact Number *

Responsible Clinician Name *

Responsible Clinician Address *

Responsible Clinician Contact Number *

Safety Information

Do you have a pacemaker, cochlea implant or neurostimulator? *

Have you had surgery to your head or heart? *

Have you ever had any metal fragments in your eyes?*

Do you have any metal prosthesis? *

Could you be pregnant? *

Patient Declaration

The details I have provided are correct and to the best of my knowledge.
I understand that the scan report will be sent to my designated clinician within 48 hours and to me within 5 working days.
I agree it is my responsibility to discuss my results with the appropriate clinician.
I have given accurate information to the best of my knowledge within the safety information section.
I have read and understood the self-referral criteria.

I agree to the above patient declaration. *

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