Request an MRI Appointment

Appointment request form

On submitting this form please be advised that one of our dedicated MRI receptionists will be in contact with you to arrange a date and time for your examination.

It is important that you answer these questions accurately as it directly relates to your safety.

If you are unsure on any of these questions they will be clarified upon booking.

Your information is sent directly and securely to South East Radiology. We take confidentiality seriously and it is important to note that your information is entered into our patient information system. This form is not stored.

Do you have a Cardiac Pacemaker or Defibrillator?

Yes

Patient details as per referral*

This information relates to your scan

Choose a clinic*

Region to be examined*

Referral upload*

To ensure we have all the correct information, please upload your referral by clicking on the button below. Please note: you are required to upload all relevant documents if you have more than one referral.

Unlimited number of files can be uploaded to this field. 20 MB limit. Allowed types: gif, jpg, jpeg, png, pdf, doc, docx.