Form

Pro Scan Imaging

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

Please complete all fields in the form below. Incomplete submissions may delay processing. Once your referral is received, a member of our team will contact you within 12 hours to schedule your scan.

If you require a private consultation with a General Practitioner (GP) or Physiotherapist before your scan, this will be arranged for you prior to your scan appointment.

Upon receipt of the below referral form, your referral will be reviewed by one of our Consultant Radiologists or Specialist Radiographers to ensure the appropriate imaging protocol is applied. We aim to schedule MRI scans and X-rays within 48-72 hours, with a Consultant Radiologist’s report provided within 48-72 hours. Please note, CT scan availability may be more limited, typically offered within 3–5 days.

Insurance Information:
If you have health insurance coverage (e.g., Medicash or Health Shield), we can provide a receipted invoice to support your claim, subject to your policy’s terms and conditions.
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Contact 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 using the "Browse Files" option below.

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Patient Signature

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Pro Scan Imaging