Form

Pro Scan Imaging

Your Health Comes First - Easy to Access Imaging
Imaging Referral Form

Please complete the form below ensuring no field is kept blank. Once this is completed we will contact you within 12 hours to arrange your scan date and time. If you require a private GP and/or Physiotherapist Consultation prior to your scan, we can help arrange this at no additional cost within 24 hours.

Please note once we receive your referral, the request will be looked at by one of our Consultant Radiologist and/or Specialist Radiographers to ensure an accurate imaging protocol is applied for your scan. We aim to provide your scan appointment within 48 hours for MRI scans and X-rays. You will receive the Consultant Radiologist written report within 48 hours from the scan taking place. Please note availability for CT scans maybe more limited and likely to be within 3-5 days.

Note: If you have Health insurance cover such as Medicash or Health Shield, we can provide receipted invoice for you to claim back your scan cost if imaging scans are covered in your policy.
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
GP Name and Surgery Name*
Please enter scan required*
Please provide your clinical history and symptoms in full mentioning the reason for requesting a scan. This is to ensure an accurate imaging protocol is applied by our Consultants.*
Please advise of your upcoming availability when you would be available to attend for your scan appointment:*
If you have any previous Imaging reports or a referral pertaining to the scan you are requesting, please upload below.

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Pro Scan Imaging