MRI referral form - Vista Diagnostics - vistadiagnostics co 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the patient details section. Indicate the patient's title (Mr, Mrs, Miss, Dr, Other) and provide their first name, surname, date of birth, gender, mobile number, home telephone number, and email address.
3. Specify if the patient prefers an alternative location for their MRI scan by circling one of the options: Golders Green, Ealing, Stratford, or Hornchurch. Note that while preferences are noted, location cannot be guaranteed.
4. Complete the insurance information by indicating whether the patient is self-pay or insured. Include the insurer's name and policy number.
5. In the relevant clinical details section, list the region(s) to be scanned and any additional requirements such as 3T MRI or Gadolinium usage.
6. Proceed to answer safety check questions regarding cardiac pacemakers, aneurysm clips, cochlear implants, renal impairment, recent surgeries, metallic foreign bodies in eyes, breastfeeding status, and pregnancy.
7. Fill out referring clinician's details including title, name, specialty/profession. Specify how you would like to receive the report (by email, post or fax).
8. If applicable, provide details for another clinician who should receive the report.
9. Finally, sign and date the form to confirm understanding of MRI contraindications before submitting via email or fax as instructed.

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