MRI & Scan Booking Form

Please complete the form below to help us arrange your diagnostic scan and/or blood test as quickly and safely as possible.

Section 1: Personal Details

Full Name (required) Date of Birth (required) Mobile Number (required) Email Address (required) NHS Number (required) Address (required) Postcode (required)

Section 2: Scan Details

Which area of the body requires scanning? BrainSpineKneeShoulderHipPelvisAbdomenProstateFemale reproductive organsOther What is the reason for this scan? Do you have a referral letter from a GP or specialist? Yes (please upload below)No, I need to speak with your team Upload referral letter (optional, any file up to 5MB) Do you have EGFR (kidney function) blood test results within the last 3 months? (Required for contrast scans) Yes, I have results (please upload below)No, I need to arrange a test Upload EGFR results (if applicable, any file up to 5MB)

Section 3: Health & Safety

Do you have any of the following? (Tick all that apply) PacemakerCochlear implantsSurgical metal implantsClaustrophobiaNone of the above Are you pregnant or breastfeeding? (For female clients) YesNoNot applicable

Section 4: Preferred Booking Time

Preferred date for your scan (required) Preferred time of day MorningAfternoonEveningFlexible

Section 5: Additional Options

Would you like to include a blood test with your scan? Yes, I want a package (we’ll send you options)No, scan onlyNot sure - please advise me

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GP Details

Please fill in your GP details so that the final results can be emailed to them directly for interpretation.

GP/Doctor name: Email: Phone number:

Final Consent

I consent to Marylebone Diagnostic Centre contacting me to arrange my appointment and sharing details with their partner imaging centre.

Once we receive your form, a member of our team will contact you within 1 to 3 hours to finalise your booking.