Patient Details

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Address
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Relevant Clinical Details

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Safety check

 Recommended by the MHRA, the referring clinician is required to assess patient safety for MRI scans.

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Referring Clinician Details

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Practice Address
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Dislaimers

  • For the volumetric analysis, we require quality images. If we cannot retrieve the appointment data to analyse, we will retain a £100 non refundable fee.
  • I confirm that the patient has had a diagnostic MRI of their head within the last 12 months – a copy of the report is attached.
  • I confirm that myself and the patient are aware that only a volumetric scan and analysis report will be provided and not be reported by radiologist.
  • I confirm that the patient has had a volumetric scan acquired elsewhere and wish this to be imported for analysis.
  • I confirm that myself and the patient are aware that only an analysis report will be provided, and where this does not meet the required technical standards, a non-refundable amount of £100 will be retained for processing purposes.
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