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Title MrMrsMsDrProf
Your name
Your email
Date of birth:
I confirm that I am 18 years old or over.
Home Address
Contact Telephone Number
Gender MaleFemaleIntermediate
What body part is intended to be scanned? MRI ShoulderMRI ElbowMRI Wrist/HandMRI Cervical SpineMRI Thoratic SpineMRI Lumbar SpineMRI Pelvis (excluding Gynae/Prostate)MRI KneeMRI AnkleMRI Foot
Scan Justification: Please describe in detail the symptoms that you are experiencing.
Have you had this problem previously? YesNo
When did your symptoms start?
Have you had any trauma to this body part recently? YesNo
Are you currently pursuing a claim relating to personal injury? YesNo
Have you been diagnosed with any form of cancer previously? (scan must not be to monitor the progress of malignancy) YesNo
Is there an additional area you wish to be scanned? YesNo
MRI ShoulderMRI ElbowMRI Wrist/HandMRI Cervical SpineMRI Thoratic SpineMRI Lumbar SpineMRI Pelvis (excluding Gynae/Prostate)MRI KneeMRI AnkleMRI Foot
Please provide details of your Nominated Responsible Clinician (GMC registered Doctor i.e GP / Health Care Professional i.e HCPC registered practitioner)
GP Name
GP Address
GP Contact Number
Disability Status (tick all that apply) Sight ImpairmentSpeech ImpairmentHearing ImpairmentPhysical DisabilityWheelchair User "None" Do you have a cardiac pacemaker (inclduing temorary pacing wires) or a cardiac defibrillator? YesNo Have you had any speicfic head or brain surgery? YesNo Have you had any specific heart surgery? YesNo Have you had any operations on your ears, including cochlear implants? YesNo Do you have any metallic foreign bodies inside your body? (eg bullets or shrapnel), incluidng any metal fragments or particles in your eyes or eye sockets? YesNo Have you undergone a procedure involving a PillCam or endoscopy capsule? YesNo Is there any possibility that you could be pregnant? YesNo Do you have permanent makeup, tatoos or coloured contact lenses? YesNo Are you currently using any skin or medication matches, or do you have an implanted device such as an insulin pump? YesNo This form uses Akismet to reduce spam. Learn how your data is processed.
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