Mri request form 2026

1. Click ‘Get Form’ to open the MRI request form in our platform's editor.
2. Begin by filling out the Patient Information section. Use capital letters and black ink. Enter the patient's title, surname, first name, date of birth, address, postcode, telephone number, mobile number, and email address.
3. Indicate whether the patient is insured or self-funding by ticking the appropriate box. If insured, provide the insurer's name and policy number.
4. Specify the MRI appointment date and time. You can also indicate your preferred radiologist in this section.
5. In the Clinical Indication for examination field, summarize relevant medical history and findings that justify the MRI request.
6. Review contraindications carefully. Circle any that apply to ensure patient safety during the MRI procedure.
7. If applicable, provide serum creatinine levels and indicate if there is a history of dialysis.
8. Complete the Referring Consultant/GP section with all required contact information including signature and date.

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