You are welcome to use the following online forms to refer a patient to one of our facilities. I am a healthcare professional referring a patient for…

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Healthcare professionals wishing to refer a patient for imaging may complete the download or online referral form below. This form will be submitted to our appointments coordinators who will then contact the patient directly to arrange an appointment.

Patients may arrange an appointment by telephone or email, although a referral will always be required to confirm a booking.

PDF VERSION

For assistance, please call Chenies Mews Imaging Centre on 020 3887 0566 
Please complete below to refer patient for a cardiac MRI scan
  • Patient details
  • Date Format: MM slash DD slash YYYY
  • Funding details
  • Referrer's details
  • Clinical Details of Examination Required

  • Some medical devices remain unsuitable for safe MRI scanning. Please contact us if you have any concerns regarding potential contraindications.
  • Date Format: MM slash DD slash YYYY

Please download or complete online, and submit the following form and one of our referral coordinators will be happy to assist for general MRI scans enquiries.

PDF VERSION

For further assistance, please call tel: 020 3887 0566 or email referrals@cheniesmews.com

Please complete below to refer for a general MRI scan
  • Patient details
  • Date Format: MM slash DD slash YYYY
  • Insurer details (if applicable)
  • Examination / Procedure
  • Safety check
  • Please contact the Imaging Centre if there are any concerns over a contra-indication to MRI
  • Referral details
  • Date Format: MM slash DD slash YYYY